An unprecedented cholera epidemic has been sweeping across war-torn Yemen since April. Due to the conflict, aid agencies have struggled to provide
treatment on the ground and the spread of the disease has escalated to a point
where more than 5000 people a day are being infected. At the time of going
to press the death toll was 1300 and climbing, a quarter of them children.
Oxfam warns that if it is not contained it will threaten the lives of thousands
of people in the coming months.
Highlighting the danger humanitarian aid workers face in conflict zones,
the Office for the Coordination of Humanitarian Affairs (OCHA) released a
report stating that “conflict parties’ lack of respect for the fundamental tenets
of international humanitarian law and the brutality and volatility of today’s
armed conflicts make it extremely difficult and dangerous for these brave aid
workers to deliver humanitarian assistance and protection in complex emergencies”. OCHA notes that “not enough progress has been achieved since
[their previous report in] 2011, and many of the recommendations contained
in the initial report remain particularly relevant today”.
The 70th World Health Assembly held in May adopted many important
resolutions to improve public health for the world’s people. Read a summary of the key resolutions in this issue of Middle East Health. The Assembly also elected Dr Tedros Adhanom Ghebreyesus from Ethiopia as the new
Director-General of WHO. He gave a profound acceptance speech about our
shared humanity which I urge all people to watch: https://www.youtube.com/
watch?v=5oUdOYARcRA
Also in this issue, we look at healthcare tourism in Jordan and healthcare
developments in Lebanon, specifically a collaboration between a Lebanese
tech hub and the American University of Beirut to develop a first-of-its-kind
non-invasive blood glucose monitor, which participants say bodes well for
Lebanon’s move towards a knowledge economy.
In the focus on paediatrics we look at future treatments in the pipeline for
celiac disease and a study that finds that celiac disease and anorexia nervosa
diagnoses are linked.
As in each issue, this issue is full of interesting news, interviews and product reviews.
Read on…

More than 200,000 affected by
cholera epidemic in Yemen
Yemen is in the grip of a runaway cholera
epidemic that is killing one person nearly every hour and if not contained will
threaten the lives of thousands of people
in the coming months, international agency Oxfam said in statement in June.
The UN says the country is facing the
worst cholera outbreak in the world, with
suspected cases exceeding 200,000 (as of
24 June) and the number increasing at an
average of 5,000 a day.
In a joint statement, United Nations
Children’s Fund (UNICEF) Executive Director Anthony Lake and World Health
Organization (WHO) Director-General
Margaret Chan said that in just two
months, cholera has spread to almost every
governorate of this war-torn country.
Already more than 1,300 people have
died – one quarter of them children – and
the death toll is expected to rise.
“UNICEF, WHO and our partners are
racing to stop the acceleration of this
deadly outbreak,” they said, also calling on
authorities in Yemen to strengthen their
internal efforts to stop the outbreak from
spreading further.
Cholera has affected around 268 districts in 20 of Yemen’s 22 governorates.
While cholera is endemic in Yemen, the

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country has experienced a surge in cholera
cases since 27 April 2017.
Sajjad Mohammed Sajid Oxfam’s Yemen Country Director said: “Yemen is on
the edge of an abyss. Lives hang in the
balance. Two years of war has plunged the

country into one of the world’s worst humanitarian crises and at the risk of famine.
Now it is at the mercy of a deadly and rapidly spreading cholera epidemic. Cholera
is simple to treat and prevent but while the
fighting continues the task is made doubly
difficult. A massive aid effort is needed
now. Those backers of this war in Western
and Middle Eastern capitals need to put
pressure on parties to the fighting to agree
a ceasefire to allow public health and aid
workers to get on with the task.”
The more than two-year conflict in
the country has devastated the country’s
health facilities; less than half are fully
functional and many public health professionals have not been paid in months. Key
infrastructure, including water and sanitation facilities, are collapsing, contributing
to the spread of diarrhoeal disease. The
weather is also playing a role: the pathogens that cause cholera are more likely to
spread in warmer weather and heavy rains
in April / May washed piles of uncollected
waste into water sources.
“We see that the numbers are going up,

Aid groups unable to manage war zone risks – OCHA, NRC report
Humanitarian aid workers want to help people in some of the biggest war zones, but
extreme risks and threats are paralyzing their operations, a United Nations-backed
report concluded recently.
“‘Conflict parties’ lack of respect for the fundamental tenets of international humanitarian law and the brutality and volatility of today’s armed conflicts make it extremely difficult and dangerous for these brave aid workers to deliver humanitarian
assistance and protection in complex emergencies,” said UN Emergency Relief Coordinator Stephen O’Brien, whose Office for the Coordination of Humanitarian Affairs
(OCHA) co-produced the report.
Presence and Proximity: To Stay and Deliver, Five Years On <http://reliefweb.int/report/world/presence-and-proximity-stay-and-deliver-five-years>, produced by OCHA,
the Norwegian Refugee Council (NRC) and Jindal School of International Affairs
in India, is based on interviews with more than 2,000 international and national aid
workers, and includes case studies on humanitarian aid in Afghanistan, the Central
African Republic (CAR), Syria and Yemen.
“It is our duty as aid workers to work where needs are greatest,” said Jan Egeland,
Secretary General of NRC. “But our international humanitarian community is failing
too many people in too many places, from Syria and Yemen to South Sudan and Nigeria. Extreme risks and threats are paralysing too many organizations and their ability
to deliver aid and save lives.”
Among its findings, the report found that as overall needs in the field have grown, so
have the funding gaps, which necessitate cutting of projects and aid work.

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On 30 May 2017 at the Al Sab’een Hospital
in Sana’a, Yemen, a doctor checks on a girl
suffering from cholera.

it’s really important to race against the spread and try to get treatment and water and sanitation measures to every corner, especially
to those corners that are basically exporting the bacteria to other
places,” Tarik Jasarevic a spokesperson for WHO said in June.
And although cholera can be treated quickly if caught early,
WHO reiterated that getting help in a middle of a conflict “is
not so easy.”
WHO and health partners are actively supporting the Ministry
through a cholera task force to improve cholera response efforts at
the national and local levels. As of 21 June, WHO has helped to
set up 144 diarrhoea treatment centres and 206 oral rehydration
points, along with more than 1,900 beds for cholera patients in 20
governorates.
The agency added that its health, water, sanitation and hygiene
partners need $66.7 million to scale up the cholera response.
Meritxell Relaño, the UNICEF Representative in Yemen,
said: “With no end in sight to the conflict, the cholera outbreak
– and potentially other disease will continue to stalk the lives
of children.”
Oxfam said that the outbreak is set to be one of the worst this
century if there is not a massive and immediate effort to bring it

On 12 May 2017 at the Sab’een Hospital in
Sana’a, Yemen, a child with severe diarrhoea
or cholera receives treatment.

On 12 May 2017 at the Sab’een Hospital in Sana’a,
Yemen, patients suffering from severe diarrhoea
or cholera receive treatment.

under control. It is calling on rich countries and international
agencies to generously deliver on promises of $1.2bn of aid they
made last month.
On June 23, the European Commission issued a statement saying it
was scaling up its response with an additional Euro 5 million, bringing
total EU support for efforts to tackle the disease to Euro 8.8 million.
Christos Stylianides, European Commissioner for Humanitarian Aid and Crisis Management, said: “The cholera outbreak in
Yemen continues to spread dramatically during the last weeks and
warrants urgent action. Crucially, humanitarian organisations
must be allowed full access to do their life-saving job. While we
do all we can to help those in need, only a political solution will
bring this catastrophe to an end.”

Based on interviews with aid workers, the authors also concluded that abductions of workers are on the rise, criminality
is seen as a rising threat, and the number of incidents against
national aid workers has increased.
“Humanitarians expressed an increased sense of risk and vulnerability, even though most major security incidents affecting
humanitarians occur in a very small number of countries and
tend to reflect the increased level of humanitarian activity in
proximity to ongoing conflict rather than expanded targeting
of humanitarians around the world,” the authors wrote.
The report is a five-year follow-up to the 2011 document,
‘To Stay and Deliver’, which provided advice and recommendations to practitioners on critical issues, such as risk management, responsible partnerships, adherence to humanitarian
principles, acceptance and negotiations with relevant actors.
Among the conclusions, the authors wrote that “not enough
progress has been achieved since 2011, and many of the recommendations contained in the initial report remain particularly relevant today”.
Other trends noted that humanitarians are more focused on
security analysis, and that remote programming – the concept
of using local organizations to help implement aid activities –
can generate risks and undermine the quality of protection and
humanitarian programmes.

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H E A L T H I 7

GE signs MoU with Saudi Arabia
to support kingdom’s Vision 2030
GE has signed a range of Memorandums of
Understanding [MoU] with the Kingdom
of Saudi Arabia in an effort to support the
delivery of Saudi Vision 2030. The MoUs
cover multiple sectors and partners and
aim to create a diverse and sustainable
economic platform in the kingdom.
The initiatives touch upon the key pillars
within Saudi Vision 2030, focusing on transforming the nation into a global investment
leader and geographic hub and the upscaling
of industrial skills and capabilities.
The agreements also place significant
emphasis on human capital development
and the digital transformation across multiple sectors, with the expanded application of GE’s Predix platform, which utilizes
cloud-based data analytics to better ensure
and enhance manufacturing efficiency.
The transformation of the healthcare
industry is a main priority of the government, which is looking to offer services
and research capabilities on par with
leading nations in healthcare around the
world. Through five different partnerships with King Faisal Specialist Hospital
[KFSH], Dr. Sulaiman Al Habib Medical Group, the Saudi Telecom Company
[STC], King Fahad Medical City [KFMC]
and the Saudi Industrial Clusters Development Program [NICDP] respectively,
GE is providing expertise, equipment and
cutting-edge digital solutions to ramp-up
national healthcare competencies.
King Fahad Specialist Hospital
(KFSH) – Through their partnership,
KFSH and GE are aiming to establish a
long-term technology management partnership for both GE and non-GE equipment, and in so doing establishing KFSH
as a Digital Hospital, making use of advanced analytics, information technology
systems and infrastructure. Education is
a crucial component of this agreement,
which will see the development of clinical, technical medical and leadership
educational programs.
Dr Sulaiman Al Habib Medical Group
(HMG) – GE and HMG are collaborating
to deploy and develop a Hospital Information Solution through GE’s Predix, with

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the goal to deploy it in Saudi Arabia and
across the region.
STC, MoH – The landmark agreement
between STC and GE, under the patronage of the Saudi Ministry of Health, is a
vital element in the digitization of industry in the Kingdom. The three partners
will introduce digital solutions through
an Electronic Medical Records Predix
Solution and a Centralized Appointment
System, which together will serve to transform the centers into ‘digital hospitals.’
King Fahad Medical City (KFMC) – The
partnership between KFMC and GE Healthcare focuses on the radiology privatization
proof-of-concept for the medical imaging
department at King Fahad Medical City and
nearby hospitals, in addition to providing an
operator to validate the government-wide
operations over a 10-year period.
NICDP – This cooperation agreement
will foster collaboration across multiple
fronts in the development of biopharmaceutical capabilities in the Kingdom,
stressing the importance of vaccine research and the development of local capabilities, eventually leading to the initiation of a bio-science park.
Report outlines changes required
for improved healthcare in GCC
Dramatic economic growth fuelled by
high oil prices since the early 2000s has
brought rapid cultural change and resulted
in a shift in lifestyle and dietary habits,
leading to a rise in non-communicable
diseases. In a new report, ‘Diagnosing
healthcare in the GCC: A preventative approach’, <www.eiuperspectives.economist.
com/healthcare/diagnosing-healthcare-gcc-0>
sponsored by Abbott, The Economist Intelligence Unit (EIU) reviews the health
challenges facing the population in the six
Gulf Co-operation Council (GCC) states
– Bahrain, Kuwait, Oman, Qatar, Saudi
Arabia and the UAE – and highlights the
need for early diagnosis and preventative
healthcare strategies.
The key sentiment among regional
healthcare experts is that healthcare delivery should be the mandate of the private sector, while the public sector should
be responsible for planning, oversight and

H E A L T H

clinical governance. Improved efficiency –
in terms of better utilisation of resources
and improved patient turnaround times
– will drive the system towards faster and
more effective diagnosis. Government
oversight will be essential to ensure that
the private sector is operating as it should.
A central component of the healthcare system critical to early diagnosis is
pathology, driving an estimated 70% of
all healthcare decisions. Ensuring adherence to quality assurance protocols in
laboratories will therefore be essential. In
particular, ongoing training for laboratory
technicians, provided by local educational
facilities, will help to standardise testing
procedures across the region.
Another component is insurance. To
comply with the new insurance laws in the
GCC, many companies are offering their
employees a basic insurance package. In
most cases, regular screenings and sophisticated testing are not covered. A framework must be developed to cover such
tests if a genuine need can be identified.
The proliferation of insurance coverage
has led to egregious doctor-incentivising
practices. Enforcing regulation on incentivising of medical professionals will improve
transparency and patient trust in the Gulf.
Increased data capture and record-keeping,
through systems such as Dubai’s “e-claim”,
will shed more light on such practices,
identifying instances where unnecessary
tests are performed. In addition, individual
health records will provide medical practitioners with detailed patient histories,
which will lead to better diagnosis.
Melanie Noronha, the editor of the report, said: “Governments must develop a
combined primary, secondary and tertiary
prevention strategy to facilitate early diagnosis and preventative healthcare. A
holistic strategy will entail educating the
public about the need for regular screenings while improving access to these programmes, to create a system in which early
diagnosis is possible.”
UAE MoH signs MoU with Sanofi
to tackle non-communicable diseases
The UAE Ministry of Health & Prevention
has signed a Memorandum of Understand-

ing (MoU) with Sanofi to initiate comprehensive measures for the prevention of
non-communicable diseases in the country.
The collaborative initiative aims to develop programs that will help enhance the skills
of healthcare professionals for better disease
management, implement national health
awareness activities, and improve education
and training on pharmaco-economics. The
objective of the MoU is to reinforce support for all the key stakeholders involved
in the healthcare sector including, regulators, health authorities, healthcare providers
(HCPs) and, patients and caregivers.
The initiative involves customized outreach activities designed to effectively
educate various stakeholders and target
groups for different disease areas.
Dr Hussein Abdul Rahman Al Rand,
Assistant Undersecretary for the Ministry’s
Health Centers and Clinics Sector and Public Health, said: “The healthcare system in
the UAE is taking every step to control the
prevalence of preventable diseases among
communities. Non-Communicable diseases
such as diabetes and cardiovascular disease
pose a threat to the health of the Emirati
population and citizens. The incidence of
these conditions can be greatly reduced if
preventive and curative interventions are
implemented effectively. Collaborative
public-private partnerships are critical to
achieving our healthcare goals and securing the future of the country. In line with
this, we are happy to have Sanofi’s support
in helping us strengthen the healthcare infrastructure in the UAE.”
To encourage two-way communication between patients, caregivers and the
public, an integrated smart phone app will
be developed to help maximize access to
healthcare services.
The MoU also focuses on enhancing
laboratory capabilities and genetic assay
expertise by offering access to high-quality diagnostic testing for newborn babies,
and free of cost testing for patients with
high risk of LSDs (Lysosomal Storage
Disorders). The long-term plan involves
establishing disease registries, collecting
epidemiological data, and driving awareness campaigns and screening programs
on rare diseases.

Map of verified attacks – developed from shared information by WhatsApp group

WhatsApp enables monitoring of attacks
on healthcare workers in Syria
The messaging service Whatsapp is being
used in Syria to help monitor and collect
data on attacks on healthcare workers and
facilities, providing robust data in support
of advocacy and accountability efforts.
The system, which enables teams to
share data about attacks within 24 hours,
identified 402 attacks against health care
in Syria between November 2015 and December 2016, according to a new study in
The Lancet. The study shows that during
this year of the study, nearly half of hospitals in non-government controlled areas
were attacked and a third of services were
hit more than once.
Attacks on health care have reached
unprecedented levels in Syria, now in its
7TH year of conflict. Collecting robust
and reliable data is important to convince
the international community to enforce
legal protections, and to achieve accountability for widespread breaches of international law.
While reporting of attacks has improved,
until now there has been no standardised
method of collecting robust data. Collecting first-hand accounts from people on
the ground can result in limited coverage,
and using second-hand data such as media
reports, satellite images and retrospective
accounts can result in incomplete data,
and collection is hampered by access constraints, security fears and concerns about
confidentiality.
Following the 2010 UN General Assembly Resolution that threats to health care
should be addressed, the WHO was tasked
to develop a method of collecting more re-

liable data on attacks on health care.
The new tool was piloted by the Health
Cluster in Gaziantep, Turkey, which coordinates humanitarian activities in Syria,
including the UN and around 50 NGOs.
The Health Cluster supports 352 health
facilities in Syria, serving a population of
approximately 5.5 million people.
The monitoring tool uses a 293-member WhatsApp group. When an incident
occurs, a short message is posted to the
group. All members with physically-verified information (i.e., who have visited
the site or were present – not hearsay) are
then asked to complete an anonymous and
confidential online form to detail location,
attack type (e.g. aerial bombardment, gunfire, arson), facility type, extent of damage,
who was affected, injuries and deaths.
Within 24 hours, the team in Turkey
issues a flash update to key partners, the
WHO, UN and donors. Every month,
data is verified by checking health cluster alerts against external reports. Reports
that remain unverified because of insufficient information are also recorded
From November 2015 to December
2016, 402 individual attacks were identified, of which 158 were verified. A total
of 938 people were harmed, a quarter of
whom were health workers. Nearly half
(44%) of hospitals in non-government
controlled areas were attacked and a third
of services were hit more than once. Services providing trauma care were attacked
more than other services. Aerial bombardment was the main weapon, and land operations to take over a specific location
were associated with increased attacks.
Dr Alaa Abou Zeid, Emergency Health

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H E A L T H I 9

Coordinator, WHO Health Cluster, Gaziantep (now Health Cluster Coordinator,
WHO, Yemen) and lead author of the paper, says: “On a daily basis, we have witnessed the efforts that partners do to keep
health facilities operational, including dividing facilities, such as operating theatres
and post-operative care, among locations
to try to reduce the risk that all services are
affected, or moving entire services underground. Our challenge now is to convince
our colleagues on the ground to continue
collecting and verifying data, when they
have still not seen a reduction in attacks.
We urge the international community to
mobilise and apply the Geneva Convention with conviction in order to effectively
protect health care and similar civilian services in conflict.”
Need for improved evidence – The paper is part of a wider four-paper Series, led
by researchers from the London School of
Hygiene & Tropical Medicine, UK, assessing
the evidence base for health interventions in
humanitarian crises. Large-scale humanitarian crises are ongoing in Syria, Afghanistan,
Central African Republic, DR Congo, Iraq,
Libya, Nigeria, Somalia, South Sudan, and
Yemen among others.
Worldwide, an estimated 172 million
people are affected by armed conflict, including 59 million people displaced - the
highest number since World War 2. In addition to these man-made crises, 175 million people are affected by natural disasters
each year.
The four-paper Series reveals significant variations in the quantity and quality of evidence for health interventions in
humanitarian crises, and brings together
lessons learned from recent failures in humanitarian crises to provide recommendations to improve a broken system.
Professor Francesco Checchi, London
School Hygiene & Tropical Medicine, and
lead author for the Series, says: “Timely
and robust public health information is
essential to guide an effective response to
crises, whether in armed conflicts or natural disasters. Yet insecurity, insufficient resources and skills for data collection and
analysis, and absence of validated methods
combine to hamper the quantity and qual-

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ity of public health information available
to humanitarian responders. Far greater
investment and collaboration across academic and operational agencies is needed
to generate reliable evidence, and improve
the response to humanitarian crises.”
Professor Paul Spiegel, Johns Hopkins
Bloomberg School of Public Health, Baltimore, USA, and Series co-author adds:
“The humanitarian system is broken. An
unprecedented number of large-scale humanitarian emergencies are taking place,
from Syria to South Sudan and Yemen,
causing the largest number of people in a
generation to be forcibly displaced. The
existing humanitarian system was created for a different time and is no longer
fit for purpose. Major changes are now
needed to put the protection of humanitarian workers front and centre, to align
humanitarian interventions with development programmes, to improve leadership and coordination and to make interventions more efficient, effective and
sustainable.”
Polio outbreak in Syria
The Global Polio Eradication Initiative
(GPEI) reports 8 June 2017 that a
circulating vaccine-derived poliovirus
type 2 (cVDPV2) outbreak has been
confirmed in the Deir-Ez-Zor Governorate
of the Syrian Arab Republic. The virus
strain was isolated from two cases of
acute flaccid paralysis (AFP), with onset
of paralysis on 5 March and 6 May, as
well as from a healthy child in the same
community.
Outbreak response plans are being
finalized, in line with internationallyagreed outbreak response protocols,
including plans for targeted vaccination
campaigns to rapidly raise population
immunity. An initial risk analysis has been
conducted, finding low overall population
immunity levels in the area but solid levels
of disease surveillance. Active searches
are being conducted for additional cases
of acute flaccid paralysis.
Surveillance
and immunization activities are also being
strengthened in neighbouring countries.
Although access to Deir-Ez-Zor is
compromised due to insecurity, the

H E A L T H

Governorate has been partially reached by
several vaccination campaigns against polio
and other vaccine-preventable diseases
since the beginning of 2016. Most recently,
two campaigns have been conducted in
March and April 2017 using bivalent
oral polio vaccine (OPV). However, only
limited coverage was possible through these
campaigns. Syria also introduced two doses
of inactivated polio vaccine in the infant
routine immunization schedule in 2018.
The
detection
of
the
cases
demonstrates that disease surveillance
systems are functional in Syria. The
polio programme is working with local
authorities and organisations on the
ground to respond immediately, using
proven strategies. In 2013-2014, Deir-EzZor was the epicentre of a wild poliovirus
type 1 (WPV1) outbreak, resulting in
36 cases at the time. This outbreak was
successfully stopped; the now-detected
cVDPV2 strain is unrelated to the WPV1
outbreak.
Circulating VDPVs are extremely
rare forms of poliovirus, mutated from
strains in the oral polio vaccine (OPV)
that can emerge in under-immunised
populations. OPV has been a critical
tool in eliminating 99.9% of polio cases
worldwide, and while cVDPV is rare, the
GPEI is actively working with countries
to eradicate both vaccine-derived and
wild polio. The same strategies that
are eliminating wild poliovirus also
stop cVDPV – it remains critical that
all countries maintain strong disease
surveillance and ensure all children are
vaccinated.

worldwide monitor
Update from around the globe
Most of 3000 adolescent deaths
a day are preventable
More than 3000 adolescents die every day,
totalling 1.2 million deaths a year, from
largely preventable causes, according to a
new report from the World Health Organization (WHO) and partners. In 2015,
more than two-thirds of these deaths occurred in low- and middle-income countries in Africa and South-East Asia. Road
traffic injuries, lower respiratory infections
and suicide are the biggest causes of death
among adolescents.
Most of these deaths can be prevented
with good health services, education and social support. But in many cases, adolescents
who suffer from mental health disorders, substance abuse or poor nutrition cannot obtain
critical prevention and care services – either
because the services do not exist, or because
they do not know about them.
In addition, many behaviours that impact health later in life, such as physical
inactivity, poor diet, and risky sexual behaviours, begin in adolescence.
“Adolescents have been entirely absent
from national health plans for decades,”
says Dr Flavia Bustreo, Assistant DirectorGeneral, WHO. “Relatively small investments focused on adolescents now will
not only result in healthy and empowered
adults who thrive and contribute positively to their communities, but it will also result in healthier future generations, yielding enormous returns.”
Data in the report, Global Accelerated Action for the Health of Adolescents
(AA-HA!): Guidance to Support Country
Implementation, reveal stark differences in
causes of death when separating the adolescent group by age (younger adolescents
aged 10-14 years and older ones aged 1519) and by sex. The report also includes
the range of interventions – from seat-belt
laws to comprehensive sexuality education
– that countries can take to improve their
health and well-being and dramatically
cut unnecessary deaths.
Road injuries
In 2015, road injuries were the leading
cause of adolescent death among 10 to

19-year-olds, resulting in approximately
115,000 adolescent deaths. Older adolescent boys aged 15 to 19 years experienced
the greatest burden. Most young people
killed in road crashes are vulnerable road
users such as pedestrians, cyclists and motorcyclists.
However, differences between regions
are stark. Looking only at low- and middleincome countries in Africa, communicable
diseases such as HIV/AIDS, lower respiratory infections, meningitis and diarrhoeal
diseases are bigger causes of death among
adolescents than road injuries.
Lower respiratory infections
and pregnancy complications
The picture for girls differs greatly. The
leading cause of death for younger adolescent girls aged 10-14 years are lower
respiratory infections, such as pneumonia
– often a result of indoor air pollution from
cooking with dirty fuels. Pregnancy complications, such as haemorrhage, sepsis,
obstructed labour and complications from
unsafe abortions, are the top cause of death
among 15 to 19-year-old girls.
Self-harm and suicide
Suicide and accidental death from selfharm were the third cause of adolescent
mortality in 2015, resulting in an estimated 67,000 deaths. Self-harm largely occurs
among older adolescents, and globally it is
the second leading cause of death for older
adolescent girls. It is the leading or second
cause of adolescent death in Europe and
South-East Asia.
Vulnerable population
Adolescent health needs intensify in humanitarian and fragile settings. Young
people often take on adult responsibilities, including caring for siblings or working, and may be compelled to drop out
of school, marry early or engage in transactional sex to meet their basic survival
needs. As a result, they suffer malnutrition, unintentional injuries, pregnancies, diarrhoeal diseases, sexual violence,
sexually-transmitted diseases and mental
health issues.

Interventions
“Improving the way health systems serve
adolescents is just one part of improving
their health,” says Dr Anthony Costello,
Director, Maternal, Newborn, Child and
Adolescent Health, WHO. “Parents, families and communities are extremely important, as they have the greatest potential to
positively influence adolescent behaviour
and health.”
The AA-HA! Guidance recommends
interventions across sectors, including comprehensive sexuality education
in schools; higher age limits for alcohol
consumption; mandating seat-belts and
helmets through laws; reducing access to
and misuse of firearms; reducing indoor air
pollution through cleaner cooking fuels;
and increasing access to safe water, sanitation and hygiene. It also provides detailed
explanations of how countries can deliver
these interventions with adolescent health
programmes.
Hospitals treated as targets
by parties to conflict – UN chief
Parties to conflict are treating hospitals and
clinics as targets, rather than respecting
them as sanctuaries, United Nations Secretary-General António Guterres warned
in May at a Security Council debate on the
protection of civilians in armed violence.
“Despite our efforts, civilians continue
to bear the brunt of conflict around the
world,” Guterres told the 15-member body,
stressing that attacks on medical staff and
facilities continue in conflict zones. Alongside him were Christine Beerli, Vice-President of the International Committee of
the Red Cross (ICRC) and Bruno Stagno
Ugarte, Deputy Executive Director for Advocacy of Human Rights Watch.
The UN chief recalled that last year, the
Council took specific action to improve
the protection of medical care during conflict, by adopting Resolution 2286, which,
among others, urged ‘States and all parties to armed conflict to develop effective
measures to prevent and address acts of
violence, attacks and threats against medical personnel and humanitarian personnel
exclusively engaged in medical duties.

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H E A L T H I 11

worldwide monitor
Update from around the globe
In August, his predecessor submitted
recommendations for the swift implementation of this resolution.
“But on the ground, little has changed,”
Guterres warned, citing statistics from
the World Health Organization showing
that attacks on medical care took place
in at least 20 countries affected by conflict in 2016.
In Syria, Physicians for Human Rights
has documented more than 400 attacks
on medical facilities since the conflict
began. More than 800 medical staff have
been killed, and more than half of all
medical facilities are closed or are only
partially functioning, with two-thirds of
specialized medical personnel having fled
the country.
In Yemen, just a few months after the
adoption of resolution 2286, 15 people
including three medical staff were reported killed when a hospital was hit in
an airstrike.
In Afghanistan, the number of reported attacks against health facilities and
personnel almost doubled in 2016 compared with 2015.
In South Sudan, after years of attacks,
less than 50% of medical facilities are
functional in areas affected by conflict.
“These attacks are evidence of a broader trend: parties to conflict are treating
hospitals and health clinics as targets,
rather than respecting them as sanctuaries,” Guterres said.
He went on to highlight the three main
protection priorities; ensure greater respect
for international humanitarian and human
rights law; stepping up the protection of
humanitarian and medical missions, by implementing his predecessor’s recommendations on Security Council resolution 2286
(2016); and preventing forced displacement and finding durable solutions for refugees and internally displaced people.
On the third point, he stressed the need
to address the root causes of conflicts that
are driving displacement, by investing in
inclusive and sustainable development, promoting all human rights and the rule of law,
strengthening governance and institutions,

12 I M I D D L E

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and enhancing mediation capacity, from
communities to national governments.
“Preventing and ending conflict is my
first priority,” he declared. “I call on you
all to make it yours, for the sake of the
millions of civilians who are suffering
around the world.”
Major research funders to implement WHO
standards on reporting clinical trial results
Some of the world’s largest funders of medical research and international non-governmental organizations have agreed on
new standards that will require all clinical
trials they fund or support to be registered
and the results disclosed publicly.
In a joint statement in May, the Indian
Council of Medical Research, the Norwegian Research Council, the UK Medical
Research Council, Médecins Sans Frontières and Epicentre (its research arm),
PATH, the Coalition for Epidemic Preparedness Innovations (CEPI), Institut
Pasteur, the Bill & Melinda Gates Foundation, and the Wellcome Trust agreed to
develop and implement policies within
the next 12 months that require all trials they fund, co-fund, sponsor or support
to be registered in a publicly-available
registry. They also agreed that all results
would be disclosed within specified timeframes on the registry and/or by publication in a scientific journal.
Currently, about 50% of clinical trials go
unreported, according to several studies, often because the results are negative. These
unreported trial results leave an incomplete
and potentially misleading picture of the
risks and benefits of vaccines, drugs and
medical devices, and can lead to use of suboptimal or even harmful products.
“Research funders are making a strong
statement that there will be no more excuses on why some clinical trials remain
unreported long after they have completed,” said Dr Marie-Paule Kieny, Assistant
Director-General for Health Systems and
Innovation at WHO.
The signatories to the statement also
agreed to monitor compliance with registration requirements and to endorse

H E A L T H

the development of systems to monitor
results reporting.
“We need timely clinical trial results
to inform clinical care practices as well
as make decisions about allocation of resources for future research,” said Dr Soumya Swaminathan, Director-General of
the Indian Council of Medical Research.
“We welcome the agreement of international standards for reporting timeframes
that everyone can work towards.”
In 2015 WHO published its position
on public disclosure of results from clinical trials, which defines timeframes within
which results should be reported, and calls
for older unpublished trials to be reported.
That position builds on the World Medical Association’s Declaration of Helsinki
in 2013. Today’s agreement by some of
the world’s major research funders and international NGOs will mean the ethical
principles described in both statements
will now be enforced in thousands of trials
every year.
Dr Trevor Mundel, President, Global
Health, Bill & Melinda Gates Foundation, said: “It’s a 21st-century best practice – and an essential part of the social
contract that underlies medical research
– that clinical trial data should be made
publicly available less than one year after
a clinical trial’s completion. We strongly
support WHO’s effort to establish a global standard for reporting data within this
timeframe, which is a practice we require
of our grantees as well.”
“Requiring summary results of clinical
trials to be made freely available through
open access registries within 12 months of
study completion is good for both science
and society,” said Dr Jeremy Farrar, Director of the Wellcome Trust. “Not only will
this help ensure that these research findings are more discoverable, but it will also
reduce reporting biases, which currently
favour publication of trials which have a
positive outcome.”
Most of these trials and their results will
be accessible via WHO’s International
Clinical Trials Registry Platform, a unique
global database of clinical trials that com-

piles data from 17 registries around the
world, including the United States of
America’s ClinicalTrials.gov, the European Union’s Clinical Trials Register, the
Chinese and Indian Clinical Trial Registries and many others.
Dr Micaela Serafini, Medical Director,
Médecins Sans Frontières, said: “Timely
reporting of all clinical trial results is of upmost importance to MSF allowing fully informed decisions when it comes to health
strategies, treatments and diagnostics. We
fully support this move towards increased
transparency and accountability in clinical
research.”
WHO International Clinical
Trials Registry Platform
www.who.int/ictrp
Life expectancy set to increase
in developed nations, potentially
surpassing 90 years in some countries
Life expectancies in developed countries
are projected to continue increasing, with
women’s life expectancy potentially surpassing 90 years old in South Korea by
2030, according to a study published in
The Lancet.
The study predicts life expectancy is
likely to be highest in South Korea (90.8
years old), France (88.6 years old) and
Japan (88.4 years old) for women, and in
South Korea (84.1 years old), Australia
(84.0 years old) and Switzerland (84.0
years old) for men.
The researchers advise that increasing
life expectancies will have major implications for health and social services that
will need to adapt and will require policies
to support healthy ageing, increase investment in health and social care, and possibly changes to retirement age.
“As recently as the turn of the century,
many researchers believed that life expectancy would never surpass 90 years,” said
lead author Professor Majid Ezzati, Imperial College London, UK. “Our predictions
of increasing lifespans highlight our public
health and healthcare successes. However,
it is important that policies to support the

growing older population are in place. In
particular, we will need to both strengthen
our health and social care systems and to
establish alternative models of care such as
technology-assisted home care.”
In the study, researchers used a statistical technique used in weather forecasting to determine their projections and
how certain they are. They developed 21
models to predict life expectancy in 35
developed countries – unlike most life
expectancy projections which are based
on a single model – and combined the results from these models based on how well
they performed. All the predictions in the
study come with a range of uncertainty.
For instance, there is a 90% probability
that life expectancy for South Korean
women in 2030 will be higher than 86.7
years, and a 57% probability that it will
be higher than 90 years.
Although life expectancy is predicted
to increase across all 35 countries, the
extent of the increase varies by country.
Comparing 2030 and 2010 life expectancies, female life expectancy is projected
to increase most in South Korea, Slovenia and Portugal (6.6, 4.7 and 4.4 years,
respectively). While for men life expectancy will increase most in Hungary,
South Korea and Slovenia (7.5, 7.0 and
6.4 years).
Life expectancy is predicted to increase
least in Macedonia, Bulgaria, Japan and
the USA (1.4, 1.5, 1.8 and 2.1 years) for
women, and in Macedonia, Greece and
Sweden and the USA (2.4, 2.7, 3.0 and
3.0 years) for men.
The USA is predicted to see relatively
small improvements in life expectancy
(from 81.2 for in 2010 to 83.3 in 2030
for women and 76.5 to 79.5 for men).
US life expectancy is already lower than
most other high-income countries, and is
expected to fall further behind in 2030,
potentially as a result of its large inequalities, absence of universal health insurance and of the country having the highest homicide rate, body mass index (BMI)
and death rates for children and mothers
of all high-income countries.

Conversely, South Korea’s projected
gains may be the result of continued improvements in economic status which has
improved nutrition for children, access to
healthcare and medical technology across
the whole population. This has resulted
in fewer deaths from infections and better
prevention and treatment for chronic diseases, in a way that is more equitable than
some Western countries.
As well as calculating life expectancy
at birth in 2030, the researchers projected
how long those aged 65 years were likely to
live in 2030. They found that women were
likely to live an additional 24 years in 11 of
the 35 countries, and that 65-year old men
were likely to an additional 20 years in 22
countries – illustrating that older populations are likely to continue growing across
the developed world.
With an ageing population it will be
important to help people to age healthily and ease the impact of an ageing
population on health systems through
programmes that support healthy lifestyles and detect and treat diseases early.
Providing assistive technology could also
help older people remain in their homes
by compensating for loss of mobility and
senses, while building communities that
are more accessible and providing good
transportation services could help older
people access amenities while staying in
their community for longer.
The social implications of this change
will also likely require changes to pensions
and retirement, with further payments of
social security and pensions needed to support those living longer. As a result, the
researchers propose changes to working
practice through changing retirement age
or creating schemes that allow a gradual
transition to retirement.
“Dealing with an ageing population will
require a combination of strengthening
and positioning our health and social care
systems and our societies as a whole, so as
to ensure that people age healthily, continue to contribute to society for longer,
and receive appropriate pension and care
once they age.” said Professor Ezzati.

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H E A L T H I 13

the laboratory
Medical research news from around the world

Thalamus key to holding
thoughts in the mind
Long assumed to be a mere “relay”, an
often-overlooked egg-like structure in the
middle of the brain also turns out to play a
pivotal role in tuning-up thinking circuity.
A trio of studies in mice funded by the US
National Institutes of Health are revealing
that the thalamus sustains the ability to
distinguish categories and hold thoughts
in mind.
By manipulating activity of thalamus
neurons, scientists were able to control an
animal’s ability to remember how to find a
reward. In the future, the thalamus might
even become a target for interventions to
reduce cognitive deficits in psychiatric disorders such as schizophrenia, researchers say.
“If the brain works like an orchestra, our
results suggest the thalamus may be its conductor,” explained Michael Halassa, M.D.,
Ph.D., of New York University (NYU)
Langone Medical Center, a BRAINS
Award grantee of the NIH’s National Institute of Mental Health (NIMH), and also a
grantee of the National Institute of Neurological Disorders and Stroke (NINDS). “It
helps ensembles play in-sync by boosting
their functional connectivity.”
Three independent teams of investigators led by Halassa, Joshua Gordon, M.D.,
Ph.D., formerly of Columbia University,
New York City, now NIMH director, in
collaboration with Christoph Kellendonk,
Ph.D. of Columbia, and Karel Svoboda,
PhD, at Howard Hughes Medical Institute

14 I M I D D L E

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Janelia Research Campus, Ashburn, Virginia, in collaboration with Charles Gerfen, Ph.D., of the NIMH Intramural Research Program, report on the newfound
role for the thalamus online May 3, 2017
in the journals Nature and Nature Neuroscience.
The prevailing notion of the thalamus as
a relay was based on its connections with
parts of the brain that process inputs from
the senses. But the thalamus has many connections with other parts of the brain that
have yet to be explored, say the researchers.
All three groups investigated a circuit
that connects the mid/upper (mediodorsal)
thalamus with the prefrontal cortex (PFC),
the brain’s thinking and decision making
center. Brain imaging studies have detected
decreased connectivity in this circuit in patients with schizophrenia, who often experience working memory problems.
Halassa and colleagues found that neurons in the thalamus and PFC appear to
talk back and forth with each other. They
monitored neural activity in mice performing a task that required them to hold in
mind information about categories, so that
they could act on cues indicating which of
two doors hid a milk reward.
Optogenetically suppressing neuronal activity in the thalamus blocked the
mice’s ability to choose the correct door,
while optogenetically stimulating thalamus neural activity improved the animals’
performance on the working memory task.
This confirmed a previously known role for
the structure, extending it to the specialized tasks Halassa and colleagues used and
demonstrating for the first time a specific
role in the maintenance of information in
working memory.
What kind of information was the thalamus helping to maintain? The researchers found sets of neurons in the PFC that
held in memory the specific category of
information required in order to choose
the correct door. They determined that
the thalamus did not (at least in this case)
relay such specific category information,
but instead broadly provided amplification
that was crucial in sustaining memory of
the category in the PFC. It accomplished

H E A L T H

this by boosting the synchronous activity,
or functional connectivity, of these sets of
PFC neurons.
“Our study may have uncovered the key
circuit elements underlying how the brain
represents categories,” suggested Halassa.
Gordon and colleagues saw similar results when they tested how the same circuit controlled a mouse’s ability to find
milk in a maze. The animals had to remember whether they had turned left or
right to get their reward prior to a brief
delay – and do the opposite. Also using
optogenetics, the study teased apart differing roles for subgroups of PFC neurons and
interactions with the brain’s memory hub,
the hippocampus.
Thalamus inputs to the PFC sustained
the maintenance of working memory by
stabilizing activity there during the delay.
“Top-down” signals from the PFC back to
the thalamus supported memory retrieval
and taking action. Consistent with previous findings, inputs from the hippocampus,
were required to encode in PFC neurons
the location of the reward – analogous to
the correct door in the Halassa experiment.
“Strikingly, we found two separate
populations of neurons in the PFC. One
encoded for spatial location and required
hippocampal input; the other was active
during memory maintenance and required
thalamic input,” noted Gordon. “Our findings should have translational relevance,
particularly to schizophrenia. Further
study of how this circuit might go awry
and cause working memory deficits holds
promise for improved diagnosis and more
targeted therapeutic approaches.”
In their study, the Janelia team and Gerfen similarly showed that the thalamus
plays a crucial role in sustaining short-term
memory, by cooperating with the cortex
through bi-directional interactions. Mice
needed to remember where to move after
a delay of seconds, to gather a reward. In
this case, the thalamus was found to be in
conversation with a part of the motor cortex during planning of those movements.
Neuronal electrical monitoring revealed
activity in both structures, indicating that
they together sustain information held in

the cortex that predicted in which direction the animal would subsequently move.
Optogenetic probing revealed that the
conversation was bidirectional, with cortex activity dependent on thalamus and
vice versa.
“Our results show that cortex circuits
alone can’t sustain the neural activity
required to prepare for movement,” explained Gerfen. “It also requires reciprocal
participation across multiple brain areas,
including the thalamus as a critical hub in
the circuit.”
n Watch video: Michael
Halassa - Understanding Thalamic
Function: <https://www.youtube.com/
watch?v=4yc1XFLNb7w>
l doi:10.1038/nature22073.
l doi:10.1038/nn.4568
l doi:10.1038/nature22324
Chikungunya vaccine trial begins
A clinical trial of an experimental vaccine
to prevent infection with chikungunya
virus is now enrolling healthy adult volunteers at three sites in the United States.
The Phase 1/2 trial, which is sponsored
by the US National Institute of Allergy
and Infectious Diseases (NIAID), part of
the National Institutes of Health, is being
conducted at several NIAID-funded Vaccine and Treatment Evaluation Units. The
candidate vaccine, MV-CHIKV, was developed by Themis Bioscience of Vienna,
Austria.
Although chikungunya is rarely fatal,
the mosquito-transmitted virus causes an
intense inflammatory reaction resulting in
severe joint pain, fever, rash and muscle
pain. While most symptoms usually resolve
in days, the joint inflammation can linger.
“Chikungunya virus can cause debilitating joint pain that can last for months or
even longer,” said NIAID Director Anthony S. Fauci, M.D. “A vaccine to prevent infection with this virus would be of
considerable benefit to people living in the
more than 60 countries where chikungunya transmission has occurred, as well as
travelers to those countries.”
Chikungunya virus has been endemic
in East Africa since at least the 1950s,

when it was first discovered. There it circulates among monkeys and, occasionally,
humans. The virus likely arrived in the
Caribbean in late 2013, and as of March
2017, may have infected more than two
million people in the Americas, according
to the Pan American Health Organization
(PAHO).
A 2014 Phase 1 trial of the MV-CHIKV
vaccine conducted in Austria by Themis
Bioscience showed that the experimental vaccine was safe and induced an immune response. The candidate vaccine is a
measles vaccine virus modified to produce
chikungunya virus proteins. Once inside a
human cell, the vaccine induces the production of both measles and chikungunya
proteins. The immune system then develops antibodies against those proteins, which
may protect the vaccinated person from future infection by chikungunya virus.
Led by principal investigator Patricia
Winokur, M.D., of the University of Iowa
Carver College of Medicine, the new vaccine study will enrol 180 healthy adults
ages 18 to 45 at three sites: the University
of Iowa in Iowa City; Baylor College of
Medicine in Houston; and Emory University in Atlanta. Participants will receive
two injections of either low-dose or highdose experimental vaccine or placebo.
Neither the participants nor the investigators will know whether a volunteer is receiving placebo or investigational vaccine.
The volunteers will be assigned at random
into different groups that receive the two
injections at different intervals (29, 85,
or 169 days after the initial injection) in
order to help the researchers determine
which schedule is most effective.
Clinic staff will follow up with study
participants by phone and during clinic
visits over the course of 8 to 13 months to
monitor for any adverse reactions or safety issues. The participants will provide
blood samples to be analysed for evidence
of antibody production, which would indicate that the vaccine is prompting an
immune response.
Themis Bioscience is currently conducting a Phase 2 trial in Europe with the same
vaccine candidate. Other chikungunya

vaccine candidates are also under investigation in different trials, including one
that uses virus-like particles (VLPs) to
induce an immune response in recipients.
NIAID sponsored the Phase 1 trial of the
VLP vaccine candidate; a Phase 2 trial began in 2015.
Glutamine suppresses herpes in mice
Glutamine supplements can suppress reactivation of herpes simplex virus (HSV)
in mice and guinea pigs, according to findings recently published in the Journal of
Clinical Investigation. The research was
conducted by scientists at the National Institute of Allergy and Infectious Diseases
(NIAID), part of the National Institutes
of Health, and at the US Food and Drug
Administration.
There is no cure for infection with
HSV-1 and HSV2, viruses that can cause
recurrent outbreaks of cold sores and genital sores in humans. Although antiviral
medications can help shorten outbreaks,
the virus persists in the body and can reactivate, which underscores the need for
new treatment approaches. Prior research
demonstrated the importance of HSVspecific T cells for controlling recurrent
HSV outbreaks, and that activated T cells
require increased metabolism of glutamine
(an amino acid produced by the body and
found in food). Therefore, the authors
speculated that glutamine supplementation might increase T-cell function and
improve infection control.
To test this hypothesis, scientists infected mice with HSV-1 and guinea pigs
with HSV-2 and randomly assigned the
animals to different treatment groups. Two
weeks after infection, some animals received an oral glutamine supplement and
others did not. Results showed that mice
that received glutamine were less likely to
have HSV-1 reactivation than those that
did not, and similarly, guinea pigs that received glutamine were less likely to have
recurrent outbreaks of HSV-2 than those
that did not receive the supplement.
Evaluation of host cellular gene expression in mice treated with glutamine
showed that several genes inducible by in-

M I D D L E

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H E A L T H I 15

terferon gamma (IFN-y) had an increased
response. IFN-y is produced by virus-specific T cells and can inhibit viral reactivation. Mice treated with glutamine also had
high numbers of virus-specific T cells in
infected nerve tissues. Together, the results
suggest glutamine may reduce HSV reactivation by improving the T-cell response
to infection. Clinical trials are needed to
determine whether this novel treatment
approach would effectively treat HSV in
humans, according to the authors.
l doi:10.1172/JCI88990 (2017).
Researchers connect blood brain
vessel lesions to gut bacteria
A study in mice and humans suggests that
bacteria in the gut can influence the structure of the brain’s blood vessels, and may
be responsible for producing malformations that can lead to stroke or epilepsy.
The research, published in Nature, adds to
an emerging picture that connects intestinal microbes and disorders of the nervous
system. The study was funded by the US
National Institute of Neurological Disorders and Stroke (NINDS), a part of the
National Institutes of Health.
Cerebral cavernous malformations
(CCMs) are clusters of dilated, thinwalled blood vessels that can lead to
seizures or stroke when blood leaks into
the surrounding brain tissue. A team of
scientists at the University of Pennsylvania investigated the mechanisms that
cause CCM lesions to form in genetically
engineered mice and discovered an unexpected link to bacteria in the gut. When
bacteria were eliminated the number of
lesions was greatly diminished.
“This study is exciting because it shows
that changes within the body can affect
the progression of a disorder caused by a
genetic mutation,” said Jim I. Koenig,
Ph.D., program director at NINDS.
The researchers were studying a wellestablished mouse model that forms a significant number of CCMs following the
injection of a drug to induce gene deletion. However, when the animals were relocated to a new facility, the frequency of
lesion formation decreased to almost zero.
“It was a complete mystery. Suddenly,

16 I M I D D L E

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our normally reliable mouse model was
no longer forming the lesions that we expected,” said Mark L. Kahn, M.D., professor of medicine at the University of Pennsylvania, and senior author of the study.
“What’s interesting is that this variability
in lesion formation is also seen in humans,
where patients with the same genetic mutation often have dramatically different
disease courses.”
While investigating the cause of this
sudden variability, Alan Tang, a graduate
student in Dr Kahn’s lab, noticed that the
few mice that continued to form lesions
had developed bacterial abscesses in their
abdomens – infections that most likely
arose due to the abdominal drug injections. The abscesses contained Gram-negative bacteria, and when similar bacterial
infections were deliberately induced in the
CCM model animals, about half of them
developed significant CCMs.
“The mice that formed CCMs also
had abscesses in their spleens, which
meant that the bacteria had entered the
bloodstream from the initial abscess site,”
said Tang. “This suggested a connection
between the spread of a specific type of
bacteria through the bloodstream and the
formation of these blood vascular lesions
in the brain.”
The question remained as to how bacteria in the blood could influence blood
vessel behaviour in the brain. Gram-negative bacteria produce molecules called
lipopolysaccharides (LPS) that are potent
activators of innate immune signalling.
When the mice received injections of LPS
alone, they formed numerous large CCMs,
similar to those produced by bacterial infection. Conversely, when the LPS receptor, TLR4, was genetically removed from
these mice they no longer formed CCM
lesions. The researchers also found that,
in humans, genetic mutations causing an
increase in TLR4 expression were associated with a greater risk of forming CCMs.
“We knew that lesion formation could
be driven by Gram-negative bacteria in
the body through LPS signalling,” said
Kahn. “Our next question was whether we
could prevent lesions by changing the bacteria in the body.”

H E A L T H

The researchers explored changes to
the body’s bacteria (microbiome) in two
ways. First, newborn CCM mice were
raised in either normal housing or under
germ-free conditions. Second, these mice
were given a course of antibiotics to “reset” their microbiome. In both the germfree conditions and following the course
of antibiotics, the number of lesions was
significantly reduced, indicating that
both the quantity and quality of the gut
microbiome could affect CCM formation.
Finally, a drug that specifically blocks
TLR4 also produced a significant decrease
in lesion formation. This drug has been
tested in clinical trials for the treatment
of sepsis, and these findings suggest a
therapeutic potential for the drug in the
treatment of CCMs, although considerable research remains to be done.
“These results are especially exciting because they show that we can take findings
in the mouse and possibly apply them at
the human patient population,” said Koenig. “The drug used to block TLR4 has
already been tested in patients for other
conditions, and it may show therapeutic
potential in the treatment of CCMs, although considerable research still remains
to be done.”
Kahn and his colleagues plan to continue to study the relationship between the
microbiome and CCM formation, particularly as it relates to human disease.
Sleep loss can lead to weight gain
Sleep loss increases the risk of obesity
through a combination of effects on energy metabolism. This research, presented
at the European Congress of Endocrinology in Lisbon in May, highlights how disrupted sleep patterns, a common feature of
modern living, can predispose to weight
gain, by affecting people’s appetite and responses to food and exercise.
In the 24/7 culture of the modern
world, an increasing number of people
report routine reduced quality of sleep
and several studies have correlated sleep
deprivation with weight gain. The underlying cause of increased obesity risk from
sleep disruption is unclear but may relate
to changes in appetite, metabolism, mo-

tivation, physical activity or a combination of factors.
Dr Christian Benedict from Uppsala
University, Sweden and his group have
conducted a number of human studies
to investigate how sleep loss may affect
energy metabolism. These human studies
have measured and imaged behavioural,
physiological and biochemical responses
to food following acute sleep deprivation. The behavioural data reveal that
metabolically healthy, sleep-deprived
human subjects prefer larger food portions, seek more calories, exhibit signs
of increased food-related impulsivity,
experience more pleasure from food, and
expend less energy.
The group’s physiological studies
indicate that sleep loss shifts the hormonal balance from hormones that promote fullness (satiety), such as GLP-1,
to those that promote hunger, such as
ghrelin. Sleep restriction also increased
levels of endocannabinoids, which is
known to have appetite-promoting effects. Further work from Dr Benedict’s
team shows that acute sleep loss alters
the balance of gut bacteria, which has
been widely implicated as key for maintaining a healthy metabolism. The same
study also found reduced sensitivity to
insulin after sleep loss.
Dr Christian Benedict remarked: “Since
perturbed sleep is such a common feature
of modern life, these studies show it is no
surprise that metabolic disorders, such as
obesity are also on the rise.”
Although Dr Benedict’s work has shed
light on how short periods of sleep loss
can affect energy metabolism, longerterm studies are needed to validate these
findings. The group are now investigating longer-term effects and also whether
extending sleep in habitual short sleepers
can restore these alterations in appetite
and energy metabolism.
Dr Christian Benedict said: “My studies suggest that sleep loss favours weight
gain in humans. It may also be concluded
that improving sleep could be a promising
lifestyle intervention to reduce the risk of
future weight gain.”
l doi:10.1530/endoabs.49.S28.1

Professor Sulaiman Al Zuhair

UAEU research collaboration unlocks
potential new medicine breakthrough
The process of making medicine from
microalgae – and potentially developing
new treatments for some of the world’s
most serious diseases – could be boosted
through a new discovery by an international research partnership that includes
UAEU scientists.
A scientific research group affiliated to
the university’s Chemical and Petroleum
Engineering Department and the School
of Biological Sciences at the University of
Essex in the UK has devised a mechanism
to extract proteins and pigments from microalgae, which can be used in the manufacture of medicine.
Microalgae proteins and pigments have
been effectively extracted using an enzymatic technique. Aligning with an intensive global focus on extracting medicinal
material from natural sources, the group’s
research is now turning to testing the effectiveness of the proteins and substances
extracted through their method in treating
cancer and bacterial diseases, which paves
the way for the manufacture of this innovative strand of medicine.
Professor Sulaiman Al Zuhair, of UAEU’s
Chemical and Petroleum Engineering Department, explained that research funded
by medicine companies around the world
is currently looking to invent and produce
new, non-chemical treatment options
that reduce the risk of potentially harmful
side-effects of the chemically synthesized
conventional medicine. For the project
he is involved in, he says, microalgae – a
single-cell organism – were considered to

present a potential opportunity for medical discovery.
“Specific types of microalgae are used
in the manufacture of medicine, which
is our main subject in this scientific research,” he said.
“We evaluated the effectiveness of enzymatic treatment resulting from implementing the extracted proteins and pigments from microalgae, and compared
innovative and organic natural extraction
technique with traditional treatments,
such as ultrasound waves and high-pressured water.”
According to Professor Al Zuhair, enzymatic treatment has seen “many positive and successful results” from using the
proteins extracted from the microalgae,
which was not exposed to high temperatures. The ongoing research project, he
says, is the latest step in a long relationship between UAEU scientists and studies
of microalgae.
“These studies started in the Chemical
and Petroleum Engineering Department
in UAEU’s College of Engineering in
2010, for the purpose of producing biodiesel,” he said. “The research group succeeded in increasing the percentage of oil
components from 12% to 70%.”
During deliberations and discussions
in front of the research group from the
School of Biological Sciences at the University of Essex, the different research
parties agreed to consider and focus on
other components present in the algae, in
particular the proteins and colorful substances, for the purpose of using them in
the manufacture of medicine.”

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H E A L T H I 17

Lebanon Report

Participants in the partnership between UK Lebanon Tech Hub and the American University of Beirut to develop a novel non-invasive blood glucose-monitoring device.

Tech hub partnership with
AUB develops novel blood
glucose monitoring device
A partnership between UK Lebanon Tech Hub and the American University of Beirut to
develop a first-of-its-kind non-invasive blood glucose-monitoring device is receiving praise
for its research and innovation and is being hailed as an optimistic sign of what Lebanon is
capable of in its move towards a knowledge economy.
UK Lebanon Tech Hub (UKLTH)
announced that it will fund the
research and development of ediamond
(Electromagnetic Diabetes Monitoring
Device): a one of its kind non-invasive
blood glucose-monitoring device, which
is being developed by the Maroun Semaan
faculty of Engineering and Architecture
and the Faculty of Medicine at the
American University of Beirut (AUB).
The partnership was agreed at a formal

18 I M I D D L E

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signing ceremony in May, which was
attended by Nicolas Sehnaoui, Chairman
of the board of the UKLTH, Dr Fadlo R.
Khuri, President of AUB and Dr Mohamed
Harajli, Provost of AUB, in addition to
AUB Deans of Medicine and Engineering
and Architecture and senior executives.
ediamond is a continuous glucose
monitoring wearable device that will
enable diabetic patients to check their
glucose levels without needing to come

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into contact with their blood stream,
i.e. through conventional methods such
as repeatedly pricking their finger with
a needle throughout the day. The lead
investigators of ediamond are Dr Joseph
Costantine and Dr Rouwaida Kanj from
the Maroun Semaan Faculty of Engineering
and Architecture, and Dr Assaad Eid from
the Faculty of Medicine.
Sehnaoui, Chairman of the UK
Lebanon Tech Hub, said: â&#x20AC;&#x153;The goal of

One of the most
efficient ways to
do business is to
have the initial
ideas come out
from the academic
institutions. If you
look at Silicon
Valley, New Jersey,
New York, and
Pennsylvania, most of
the companies have
intimate ties with
great universities.
this collaboration is to produce a oneof-its-kind non-invasive blood glucose
monitoring device that will make
monitoring as easy as checking the time
of day.
“With 15% of the world’s population
suffering from diabetes we believe
this device, which uses advanced
electromagnetic theory, could make
a profound difference to the lives of
hundreds of millions of people. We
hope, in particular, to empower those
patients who lack diabetes management
capabilities.”
President Khuri emphasized the
importance of universities as centres of
research for innovation and technology
start-ups. He said:
“One of the most efficient ways to do
business is to have the initial ideas come
out from the academic institutions. If
you look at Silicon Valley, New Jersey,
New York, and Pennsylvania, most of the
companies have intimate ties with great
universities.”
The collaboration between the UKLTH
and AUB demonstrates UKLTH’s
commitment to supporting applied
research projects through the recently set
up International Research Centre (IRC).
The IRC was set up to play a key
role in boosting investment in R&D in
Lebanon and the wider MENA region,
in particular by developing links between
universities and entrepreneurs. Arab
countries still lag considerably behind

other knowledge economies in terms of
investment in R&D. According to the
UNESCO Institute of Statistics, Arab
countries only allocated a maximum of
0.7% of their GDP to R&D whilst EU
countries allocated up to 3.2 % and Japan
allocated 3.6%.
However, the UKLTH believes Lebanon
has great potential to develop a world
leading knowledge economy from greater
investment in R&D. Lebanon ranks 4th
out of 144 countries in mathematics and
science education according to the World
Economic Forum’s Global Information
Technology Report. Also, more than
11% of the student population study
engineering while 9% study computer
and information technology. This has led
to Lebanon having the highest number of
engineers per capita in the world.
Lebanon’s entrepreneurial ecosystem
is developing fast, which is demonstrated
by Lebanon ICT sector’s 8% annual
growth over the last five years and the
expansion of the market to US$ 400
million by 2015, according to a recent
report by the UK Lebanon Tech Hub.
This has helped position Lebanon in the
Top 20 entrepreneurial nations of the
world in 2015 (Global Entrepreneurship
Monitor). At the same time, Lebanon
has many universities with dedicated
research policies. Based on the most
recent QS University Rankings, Lebanon
had three universities in the top 20
universities of the Arab region, including
the American University of Beirut, whose
Faculties of Medicine and Engineering and
Architecture are ranked among the top in
the MENA region.
Sehnaoui also highlighted how this
partnership with AUB is a great platform
for further collaborations. He added: “We
would like to create a direct link between
the UKLTH and AUB by connecting
our start-ups with AUB students. This
will enable the students to gain firsthand knowledge of life at a start-up and
hopefully spark their inner entrepreneur.
It will also benefit our start-ups by
providing them with interns to support
their efforts.
“We would also like to create a simple
incentive programme for professors from
around the world to visit AUB as adjunct

We would also like
to create a simple
incentive programme
for professors from
around the world to
visit AUB as adjunct
professors. Part of
the programme will
include being able to
sit on the board of
directors of our startups to offer valuable
advice. This will
benefit both parties
as it will provide
great international
experience for the
visiting professors,
and our start-ups will
have the advantage of
participating in board
meetings.
professors. Part of the programme will
include being able to sit on the board of
directors of our start-ups to offer valuable
advice. This will benefit both parties as it
will provide great international experience
for the visiting professors, and our start-ups
will have the advantage of participating in
board meetings.”
Sehnaoui also shared his optimism that
Lebanon will become a technological hub
a few years down the line, saying that he
believes in the capabilities of the Lebanese
people in terms of innovation and creation.
“It’s all about the will and the passion,
and I am very passionate about this.
“We live in fantastic times because of
the exponential growth of Information
Technology,
which
opens
great
possibilities for R&D. We live in fantastic
times, we are fantastic people, and AUB
is a fantastic university, so we can create
fantastic things.”
n More information about the UK
Lebanon Tech Hub (UKLTH) can be
found at: www.uklebhub.com/en/Home

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H E A L T H I 19

The American University
ReportMedical Center
ofLebanon
Beirut
A year of accomplishments in a nutshell

AUBMC’s new medical centre

For the past century and a half, the Faculty of Medicine at the American University of Beirut (AUBFM) has
been a driver of the historical evolution of medicine in Lebanon and the region. Innovation, initiative, and
sheer controlled risk-taking have marked the growth of the Faculty, ever since its humble beginnings one
year after the inauguration of the Syrian Protestant College in 1866.
Among AUBFM’s more than 4300 graduates are luminaries in every specialty and
leaders in many of the researches conducted
worldwide. AUBFM remains the premier
medical, educational, and research hub
in the Middle East and has more recently
established itself as a world-class research
institution, with an eye toward making an
ever-greater difference in the region.
A legacy of 150 years
To mark its tremendous legacy, and
with “Purpose. Passion. Compassion.”
as its slogan for the year 2017, AUBFM planned yearlong events composed
of medical conferences, distinguished
speaker series, national campaigns, basic life support and awareness activities, community outreach events and,
of course, alumni chapter celebrations
around the world. And perhaps the
highlight of these events was The Middle
East Medical Assembly (MEMA) which
was held in May 2017. Proving to be of
great success, MEMA presented the first
global congress on conflict medicine, focusing on the management of conflict related injuries including, but not limited
to, the pathological, psychological, nursing, nephrological, surgical, oncological,
and social manifestations of war wounds.
2020 Vision, promise and progress
Launched in 2010, the 2020 Vision is an
impactful plan for AUB’s Medical Center

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(AUBMC) and healthcare in Lebanon and
the region. The vision has proven to be
strategic, with clear goals and intricate implementation processes. Since its launching, it has generated a significant amount of
local, regional and global support. To successfully integrate their ambitious plans and
programs for growth and expansion, a major
facility expansion was proposed for the new
AUBMC 2020 Medical Complex.
Seven years after the launching of the
vision, AUBMC has achieved significant
progress of this unique and health-transforming vision. Throughout the past years,
the medical center witnessed the establishment of state-of-the-art buildings, the latest of which is the Halim and Aida Daniel
Academic and Clinical Center (ACC),
the first facility in the region to focus on
patient care, education, and research and
which is expected to welcome patients
in 2018. In addition, the facility has expanded to include several centers of excellence in oncology, neuroscience, multiple
sclerosis, and children’s’ cancer, as well as
new clinical programs, services, and units.
The Faculty of Medicine has also been acclaimed for the recruitment of over 150
top-caliber, highly specialized and accomplished physicians and scientists; hence,
reversing the brain drain.
Moving forward, AUBMC will soon be
launching their New Medical Center Expansion (NMCE) Project. The new building will make available an additional 150

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beds, satisfy the need for OR procedures,
develop revenue generating uses, and allow for Cancer & Pediatric Hospital development opportunities
The legacy continues
A key aspect for the successful implementation of the AUBMC 2020 Vision is accreditation. AUBMC is the first medical
institution in the Middle East to have
earned five international accreditations of
Joint Commission International (JCI) for
the fourth time in a row, Magnet, College
of American Pathologists (CAP), Joint
Accreditation Committee for EBMT and
ISCT Europe (JACIE), and Accreditation
Council for Graduate Medical Education
– International (ACGME-I). This is testament to its superior standards in patientcentered care, nursing, pathology/ laboratory services, and medical education.
Additionally, it received the honor of the
Meritorious Outcomes with the American
College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP).
In 2017, AUBMC Food Services Department has also earned the Safety Q Platinum
certification (QPA) granted by Boecker
Food Safety. To add to its accomplishments,
the Nuclear Medicine Division at AUBMC
has successfully undergone the International QUANUM Audit by the International
Atomic Energy Agency (IAEA), Department of Technical Cooperation, Department
of Nuclear Sciences and Applications.

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H E A L T H I 21

Lebanon Report

Clemenceau Medical
Center provides
advanced healthcare
in a luxury setting
Clemenceau Medical Center (CMC) is
a unique private 160-bed medical center
that combines luxury and technology
by integrating avant-garde treatment
and technology, 5-star luxury setting,
a healing environment, a medium
for continuous medial education and
knowledge transfer, experienced and
specialized top professionals, all under one
roof. Located in Beirut, Lebanon, CMC’s
affiliation with Johns Hopkins Medicine
and multiple accreditations by
Joint Commission International
(JCI), enables the medical center
to offer its patients superior
healthcare services embedded
within a culture of excellence and
relentless commitment for high
quality patient care.
Their aim is to set a new concept
in the regional healthcare industry
through positioning Clemenceau
Medical Center as one of premium
quality, providing private medical
services that suit different patients’
needs. The medical services offered
by CMC are geared towards
attracting patients from Lebanon, the region
and the world seeking medical/healthcare
assistance with high quality standards.
CMC’s mission and the three pillars
on which the medical center was built
upon are Safety, Caring, and Excellence.
Their adherence to patient-centered care
revolves around introducing and optimizing
new services and medical specialties by
implementing the latest medical trends and
purchasing the latest medical equipment,
so as to ensure superior quality medical
services with reasonable global prices to
patients, both local and international.
CMC Centers of Excellence include
clinical and non-clinical teams and
entities providing leadership, best
practices, research, support and training
for all medical specialties including

invasive daVinci Robotics Surgical System.
Moreover, CMC is committed to
providing a safe and excellent service by
developing a culture that is centered on
a five-star customer services much like
the services that patients expect to see
in the hotel industry. CMC goes to great
lengths to be sure that their patients feel
comfortable and safe during their entire
hospital stay. Furthermore, their services
reflect their high-level physicians and
healthcare staff, as they are the beating
heart of the institution. Hence, CMC
targets distinguished physicians practicing
abroad to join the center via a rigorous
hiring and headhunting process.
Expansion abroad
From world-class medical

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excellence

and elegant surroundings to personalized
care and services, Clemenceau Medicine
International (CMI) is committed to
extending the CMC brand and advancing
Clemenceau Medicine’s mission of patient
care both regionally and internationally.
Since 2008, CMI has followed a targeted
course of expansion, launching hospitals
and medical centers in major regional
city centers and destinations around
the Middle East, with the aim of being
recognized as the organization
that manages the finest hospitals,
diagnostic centers and clinics
wherever they are located.
All CMC-affiliated hospitals will
have the Clemenceau Medicine
culture of international standards
and relentless commitment to
patient care deeply instilled, from
the way they are architecturally
designed to the manner in which
they are operated and managed.
All medical centers will pursue
innovation in healthcare and work
hard to perfect the healthcare
experience though the latest trends
and the highest standards of medical services
and hospitality.
Currently, they are developing projects
in Riyadh and Dubai.
The importance of these hospitals and
what sets them apart from the rest of the
region is that they operate within the
Clemenceau Medicine Network, which
is an assimilated network of centers
of excellence for clinical and wellness
services, innovation, medical education,
training and research. The CMI network
benefits from the expertise of Clemenceau
Medical Center’s medical, nursing and
administrative staff which is characterized
by their international expertise through
continuous education and exchange
of knowledge with Johns Hopkins
International.

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H E A L T H I 23

Lebanon Report

Lebanese American University Medical
Center – committed to excellence
The Lebanese American University
Medical Center-Rizk Hospital in Beirut
offers its patients and the community a wide
range of medical, surgical and diagnostic
healthcare services. As the integration with
The Gilbert and Rose-Marie Chagoury
School of Medicine evolves, and necessary
resources are in place, the hospital will
operate several Clinical Centers of
Excellence.
LAU Medical Center – Rizk Hospital
currently operates the following medical
departments and divisions: Surgery;
Medical Lab, Pathology and Forensic
Medicine; Psychiatry; Obstetrics &
Gynecology;
ENT;
Anesthesiology;
Internal Medicine; Diagnostic Imaging
&
Interventional
Therapeutics;
Ophthalmology;
Pediatrics;
and
Dermatology.
The Lebanese American University
Medical Center-Rizk Hospital was
originally established in 1925 as a private
family-owned clinic. In 1957 the Rizk
Hospital was opened and was one of the
first modern hospitals in Beirut and all of
Lebanon. Over the next several decades,

the hospital was expanded with more
buildings so that by 1997 it provided a
spacious environment for the provision of
advanced healthcare.
In 2009, the Rizk family sold the
hospital to Medical Care Holding, in
which the Lebanese American University
(LAU) possesses controlling interests.
The hospital was renamed University
Medical Center – Rizk Hospital and
it now serves as the primary teaching
hospital for LAU’s schools of Medicine,
Nursing, and Pharmacy.
Surgery
The hospital provides a wide variety of
surgical procedures including bariatric,

Mission, Vision and Values
The LAU Medical Center – Rizk Hospital is guided by a strong and unwavering
commitment to achieve their mission and fulfill their vision. Physicians and employees
embrace an ethical set of values that defines who they are.

Vision
LAU Medical Center – Rizk Hospital will be the premiere academic medical center
in the Middle East by delivering outstanding, innovative, patient-centered care in
partnership with superior health professionals.

Values
“Respect – The basic dignity of the Human Person is the guiding principle in all our
policies, procedures and interactions. Human life at every step of development and
decline is precious and worthy of respect.
“Integrity – Integrity means that we are consistently truthful, that we observe ethical
standards, and that we promptly acknowledge errors.
“Compassion – Compassion is the way we share deep concern, love, and care toward
each person.
“Excellence – Excellence is the result of our willingness to be creative, and to seek new
approaches to improve the quality of our work. Excellence is our way of demonstrating
that we can always be more, and we can always be better.”

H E A L T H

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H E A L T H I 25

Jordan Report

King Hussein Cancer Center
expansion doubles capacity

Middle East Health speaks
to Dr Asem Mansour,
CEO/Director General,
King Hussein Cancer
Center in Amman about
the hospital, their care
for Syrian refugees and
center’s new extension.
Middle East Health: Do you receive foreign patients at the hospital?
Dr Asem Mansour: Yes, KHCC treats
patients from almost 20 different Arabic
countries. However, its focus, during the
last period, was dedicated to many underprivileged patients coming from conflict
countries such as Palestine, Iraq, Syria, Yemen and Sudan who would not otherwise
be able to receive the life-saving cancer
treatment they need.
MEH: What percentage of your inpatients are they?
Dr Asem Mansour: Foreign patients make approximately 27% from total KHCC inpatients
MEH: Which procedures are they mostly
seeking?
Dr Asem Mansour: They are seeking a comprehensive state-of-the-art treatment within a

26 I M I D D L E

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wide range of procedures covering areas from
consultation and second opinion, to chemotherapy or radiotherapy, which are not available in their countries, up to complex procedures in terms of complicated operations and
Bone Marrow Transplant (BMT).
MEH: Why do they choose this hospital?
Dr Asem Mansour: There are many reasons:
– We provide comprehensive cancer care:
covering all medical specialties
– Our multidisciplinary approach in
offering medical decisions which are
taken by a full team of physicians based
on an in-depth study of each case individually
– Patients are able to obtain direct consultation from the largest cancer treatment
centers in the world
– Treatment focuses on the individual
needs of each patient including: dedicated

H E A L T H

areas for children and women, family halls
and others
– Our convenient location and availability of accommodation at reasonable
cost is attractive
– There is an ease of communication in
Arabic, which is spoken fluently by all staff
– There is cultural convergence with
regards dietary habits, language, religious
beliefs
– Our medical care costs are very reasonable medical compared to other hospitals within the EU and the USA
MEH: Is the hospital engaging in any
specific marketing to attract foreign patients?
Dr Asem Mansour: The KHCC is currently serving patients in Jordan and the
Middle East region. However, and due to
the full capacity rate that the center has

continuously experienced in the previous years, it did not engage in any specific
marketing strategies for the attraction of
foreign patients. Now that the expansion is
complete, we will be looking into possible
marketing strategies that would assist in the
attraction of foreign patients. The center’s
excellent reputation and its continuous efforts to improve its quality of health care
and services is what makes most of the patients seek treatment at KHCC. And now
that the capacity has doubled, hopefully,
we will be able to take more patients in,
whether from Jordan or the region, and significantly reduce the referral refusal cases.
MEH: Is the hospital providing assistance
to Syrian refugees?
Dr Asem Mansour: Actually, KHCC has
provided and continues to provide assistance to cancer patients from the Syrian
refugees in the scattered camps in Jordan.
KHCC has set up a voluntary Fund to cover the treatment of Syrian refugees. Most
donations come from individuals (wealthy
donors) or organizations from Jordan and
abroad, but still insufficient. KHCC provided the necessary assistance and treatment to about 400 Syrian refugees, which
cost the center US$12 million.
MEH: What type of assistance are you
providing?
Dr Asem Mansour:
– Comprehensive treatment
– Financial support for free accommodation, transportation, logistics, etc.
– Psychosocial support
– Inclusion of pediatric patients in a
“Back to School” program in order for
them not to miss their right to continue
learning while receiving their treatments
at KHCC
MEH: Have there been any recent developments at the hospital that you can tell
us about?
Dr Asem Mansour: The King Hussein
Cancer Center’s recent development is
its expansion. This expansion consists of
two new towers; one for inpatients and the
other for outpatients which will lead to
doubling the capacity of the existing Center and providing improved and integrated
space for patient care, research and education. These new cutting-edge facilities will

enable us to become the main medical hub
in the Middle East for comprehensive cancer treatment and care.
The 13-floor Inpatient Tower includes:
• 179 additional patient beds (single
occupancy rooms)
• An expanded Diagnostic Imaging
and Radiotherapy Unit
• An expanded Bone Marrow Transplantation Unit
• Adult and Pediatric Specialty ICUs
• Floors specifically dedicated to pediatric patient wards
• Floors specifically dedicated to adult
patient wards
In addition to specialized outpatient clinics,
the 10-floor Outpatient Building will have:
• The first public cord bank in Jordan
• The Khalid Shoman Educational
Center and Auditorium. This comprehensive educational center will include a skills
lab, seminar rooms, a physician’s library
and a social interactive lounge.
• Dedicated spaces for women and
children, including a Women’s Health

Center and an extensive pediatric section to cope with the rising number of
pediatric cancer cases.
• A cutting- edge Cell Therapy and
Applied Genomics Department, including
state-of-the-art stem cell labs to raise the
research capacity of the Center
The new expansion will allow us to offer
double the amount of bone marrow transplants to meet the rise in demand for treatment. In addition, the new expansion will
house more ICUs so that we can continue
to offer highly specialized, around-theclock care.

Cancer Support
The fight against cancer needs
your support. You can donate,
volunteer and provide support in
numerous ways. To find out more
about this, visit: http://www.khcc.
jo/section/how-you-can-help-0

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H E A L T H I 27

Jordan Report

Specialty Hospital in Jordan, one of the top 10
hospitals in medical tourism worldwide
Middle East Health: Please give us a brief
about the Specialty Hospital in Jordan.
Eng. Shereen Abu Manneh - Head of
Marketing and Business Development:
The Specialty Hospital is a leading
private teaching hospital, located in
Amman - Jordan. It is fully equipped to
provide a full range of in-patient and outpatient diagnostic, therapeutic medical
and surgical procedures. Its capacity is
265 beds, with 1000 qualified employees
and serves 750 consultants who are
dedicated to provide high quality care to
our patients.
During the past 24 years the hospital
has provided the highest quality care to
more than 4.4 million patients, including
460,000 in-patient admissions, 920,000
ER visits and 172,000 operations for
patients.
MEH: Do you receive foreign patients at
the Specialty Hospital?
S.A.M.: Yes, the Specialty Hospital is well
known in the region for treating foreign
patients. We receive patients from more
than 50 countries. Specialty Hospital is
the first and only hospital in Jordan to
achieve the Medical Tourism Certification
from MTQUA. Recently the Specialty
Hospital was ranked in the top 10 hospitals
for medical tourism worldwide.
MEH: Do you have a special department
for foreign patients?
S.A.M.: There is an International Office
dedicated to facilitate treatment of foreign
patients. The office connects patients with

28 I M I D D L E

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the specialist prior to the patientâ&#x20AC;&#x2122;s travel.
The specialist will give initial diagnosis and
a treatment plan with the length of stay and
the estimated cost of treatment.
This office assists foreign patients
with the issuing of visas, if required,
transportation, accommodation, flight
reservation, airport pick-up, admission and
treatment, until the patient is discharged.
They also provide and a tour of Jordan
at the request of patients and their
companions. The staff at the International
Office will follow up with patients after
they have returned to their country.
MEH: Which countries do they come
from? And what procedures do they seek?
S.A.M.: Most foreign patients come
from the GCC countries and from Iraq,
Palestine, Oman, Sudan, Chad and other
countries.
Medical tourists mainly seek major
surgeries at the Specialty Hospital
including cardiac, pediatric cardiac,
bariatric surgeries, kidney transplant,
orthopedic, dental surgeries, IVF and
other sophisticated procedures. In addition
to that some choose to come for medical
checkups.
MEH: Why do they choose Specialty
Hospital?
S.A.M.: The Specialty Hospital provides
full range of procedures by highly qualified
staff and using the latest technology; it was
the first hospital in Jordan to provide HyperBaric Oxygen therapy and MRI 3 Tesla.
And recently the radiology department

H E A L T H

expanded to have the first CT 512 slices in
Jordan and the first Silent MRI.
In addition to having no waiting time,
patients also receive high quality care
since. The Specialty Hospital is one of
the most awarded and accredited hospitals
internationally. It is accredited by The
Joint Commission International (JCIA)
for three times, and accredited 3 times by
the Health Care Accreditation Council
(HCAC). Specialty Hospital is the first
and only hospital in Jordan to achieve
the Medical Tourism Certification from
MTQUA and was ranked from the top 10
hospitals in medical tourism worldwide.
Also the Specialty Hospital is first and
only hospital to achieve King Abdullah II
Award for Excellence for two consecutive
cycles. In 2012 the hospital was awarded
by Arabia500 for being from the top
500 companies in the growth rate in the
past 3 years in the region. The hospital
commitment to social responsibility
to serve the local and the neighboring
community was crowned by receiving
CSR Arabia Award.
In addition to; MECCAward, Prince
Faisal Award, ISO 9001, Occupational
Health and Safety OHSAS 18001,
Environmental
Safety
ISO14001,
Hazardous Analysis and Critical Control
Points HACCP for food safety, and
quality management system for medical
laboratories ISO 15189. In addition to all of
that the Specialty Hospital was recognized
from the Arab Hospitals Federation as The
Best Hospital in The Arab World in Patient
Centered Care.

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H E A L T H I 29

Saturn83/wikivoyage

Jordan Report
Petra, one of several UNESCO World Heritage Sites in Jordan

Interview

Attracting foreign patients with
advanced medical expertise
Jordan has achieved great strides in the medical tourism industry over the past
several years. Serving as a safe haven in the region, the kingdom is considered
the number one medical tourism destination in the MENA region. Middle East
Health spoke to Dr Fawzi Al-Hammouri, Chairman of the Private Hospitals
Association of Jordan, about the association and medical tourism in Jordan. Dr
Al-Hammouri is Honorary President of the Global Healthcare Travel Council and
a key player in the medical tourism sector in the region.
Middle East Health: What is the role
of the Private Hospitals Association in
promoting Jordan as a medical tourism
destination?
Dr Fawzi Al-Hammouri: The Private
Hospitals Association (PHA), was
established in 1984 to represent the
country’s private hospitals and raise their
reputation. PHA works diligently to
promote and defend the rights of Jordan’s
private hospitals.
Due to Jordan’s high reputation as a
medical tourism hub, we have been invited
to present Jordan’s ‘success story’ in many
medical tourism conferences and forums
internationally, where we have shared
our experience and journey with other
emerging medical tourism destinations.
MEH: Why is Jordan attractive to foreign
patients?
Dr Fawzi Al-Hammouri: With no less than
65 private hospitals, many boasting cutting
edge facilities and first-rate physicians,
Jordan is considered in the top league in the
global medical tourism market.
Since the early seventies Jordan has been
regarded as a pioneer for performing many
medical procedures in the Arab world for
the first time. These achievements have
made Jordan well known for its medical
expertise and an attractive destination for
foreign medical patients.
Jordanian physicians and surgeons have
a very good reputation. The Jordanian
Government decided that education and
investment in its human capital will be the
way to build the future of our country, so you

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will find that Jordan leads the region in the
number of physicians, nurses, pharmacists
and engineers per capita. For example,
Jordan has 29 physicians and 33 nurses and
16 pharmacists per 10,000 population. We
also invested in scholarships for our doctors
to get post graduate training and certificates
from USA, UK, Canada, Germany and
many other countries.
There is also a positive investment
environment in Jordan, which has led
to the private sector building hospitals.
More than 60% of hospitals in Jordan are
private, and they are well equipped with
the latest medical technology. Diagnostic
and therapeutic procedures are now easily
available for patients at low cost with no
waiting time and without compromising
the quality of care, which is crucial for
travelling patients.
Our hospitals apply international
quality standards. At present, 10 Jordanian
hospitals are accredited by the Joint
Commission International (JCI), with
many others in the process of obtaining
this accreditation and 25 hospitals
are accredited by the Health Care
Accreditation Council (HCAC).
Jordan boasts significant expertise in
a variety of medical specialties such as
kidney transplant, bone marrow transplant,
oncology, paediatrics, geriatrics, cardiac
surgery, orthopaedic procedures, cosmetic
surgery, dental procedures, IVF, psychiatry
and drug addiction, to name a few.
Jordan has certain characteristics that
favour it as a medical tourism destination,
such as a high level of security and

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stability compared to other countries in
the region.
Jordan’s climate is another attractive
point as in most days of the year the
weather is moderate, in addition to that
Jordan has numerous tourist attractions
and archaeological sites, several of which
are UNESCO World Heritage Sites, such
as the historic city of Petra.
Jordan had the largest natural spa on
earth which is the Dead Sea the lowest
point on earth, which has healing powers
for many diseases such as psoriasis and
pulmonary diseases.
MEH: Can you tell us about some of the
achievements of the Private Hospitals
Association?
Dr Fawzi Al-Hammouri: We at PHA are
keen to keep Jordan as the number one
medical tourism destination in the MENA
region. As a result, Jordan manages to
attract 250,000 international patients
annually, with revenue of more than
$1.2 billion. Those patients come from
62 countries, mainly from the traditional
markets such as Saudi Arabia, Iraq, Yemen,
Sudan, Libya, Palestine, Syria, Bahrain,
Oman and United Arab Emirates, in
addition to few non-traditional markets
such as the USA, Kazakhstan, Ukraine,
Russia, Chad and Nigeria.
On the back of PHA initiatives, Jordan
was awarded: The Destination of The Year
2014 by International Medical Travel Journal
(IMTJ). In October 2015, I was elected
as the president of the Global Healthcare
Travel Council for two years.

Saturn83/wikivoyage

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WHO/L. Cipriani

The 70th World Health Assembly

Promoting healthcare for humanity

32 I M I D D L E

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tors is a prime instrument for doing
so,” and to “listen to civil society”:
“Civil society organizations are
best placed to hold governments
and businesses, like the tobacco,
food and alcohol industries, accountable. They are the ones who
can give the people who suffer the
most a face and a voice.”
In closing, Dr Chan asked government representatives to: “Remember
the people…Behind every number
is a person who defines our common
humanity and deserves our compassion, especially when suffering or
premature death can be prevented.”

Resolutions
Delegates at the World Health Assembly reached a number of new
agreements including on dementia;
immunization; refugee and migrant
health; substandard and falsified
medical products; the world drug problem;
childhood obesity; pandemic influenza, and
the health workforce, among others.
Dementia
Delegates at the World Health Assembly

H E A L T H

Dr Mahmoud
M Fikri, WHO
Regional Director
for the Eastern
Mediterranean
listens to translation
of discussions at
the World Health
Assembly

WHO/L. Cipriani

In her final opening address to the World
Health Assembly as Director-General, Dr
Margaret Chan offered some advice to delegates “as you continue to shape the future
of this Organization”.
She called on the Health Assembly to
make “reducing inequalities” a guiding
ethical principle. “WHO stands for fairness,” she said. Countries should also work
to improve collection of health data and
make health strategies more accountable.
Protecting scientific evidence should
form “the bedrock of policy”, said Dr
Chan, citing vaccine refusal as one of the
reasons that the “tremendous potential of
vaccines is not yet fully realized”.
She stressed the importance of continued innovation, citing the research
partnership between WHO and others to
produce an effective and highly affordable
meningitis A vaccine that has transformed
the lives of millions of people in Africa.
“Meeting the ambitious targets in the Sustainable Development Goals depends on
innovation,” she said.
She then asked governments and partners to safeguard WHO’s integrity in all
stakeholder engagements. “The Framework for engagement with non-state ac-

WHO/L. Cipriani

The 70th World Health Assembly was held in Geneva from 22-31 May, during which a new
Director-General was elected and a wide range of important global public health issues discussed
and resolutions adopted. Middle East Health reports.

Dr Hanan Mohamed
Al-Kuwari of Qatar
chairs Committee A
at the World Health
Assembly

endorsed a global action plan on the public health response to dementia 2017-2025
and committed to developing ambitious
national strategies and implementation
plans. The global plan aims to improve the
lives of people with dementia, their families
and the people who care for them, while

decreasing the impact of dementia on communities and countries. Areas for action
include: reducing the risk of dementia; diagnosis, treatment and care; research and
innovative technologies; and development
of supportive environments for carers.
They called on the WHO Secretariat to
offer technical support, tools and guidance
to Member States as they develop national
and subnational plans and to draw up a
global research agenda for dementia. Delegates recognized the importance of WHO’s
Global Dementia Observatory as a system
for monitoring progress both within countries and at the global level.
Delegates emphasized the need to integrate health and social care approaches,
and to align actions to tackle dementia with
those for other aspects of mental health, as
well as noncommunicable diseases and ageing. They also highlighted the importance of
ensuring respect for the human rights of people living with dementia, both when developing plans and when implementing them.
Worldwide, around 47 million people
have dementia, with nearly 9.9 million
new cases each year. Nearly 60% of people
with dementia live in low- and middleincome countries.
Immunization
Delegates agreed to strengthen immunization to achieve the goals of the Global
Vaccine Action Plan (GVAP). In 2012,
the Health Assembly endorsed GVAP, a
commitment to ensure that no one misses
out on vital immunization by 2020. However, progress towards the targets laid out
in that plan is off track. Halfway through
the decade covered by the plan, more than
19 million children were still missing out
on basic immunizations.
The resolution urges Member States to
strengthen the governance and leadership
of national immunization programmes. It
also calls on them to improve monitoring
and surveillance systems to ensure that upto-date data guides policy and programmatic
decisions to optimize performance and impact. It calls on countries to expand immunization services beyond infancy; mobilize
domestic financing, and strengthen interna-

The 70th World Health Assembly

Dr Tedros Adhanom Ghebreyesus, the new Director-General of WHO

World Health Assembly elects
Dr Tedros Adhanom Ghebreyesus
as new WHO Director-General
The World Health Assembly elected Dr Tedros Adhanom Ghebreyesus as the new Director-General of WHO on 23 May. He succeeds Dr Margaret Chan, who has been WHO’s Director-General
since 1 January 2007.
Dr Tedros Adhanom Ghebreyesus was nominated by the Government of Ethiopia, and begins his five-year term on 1 July 2017.
Prior to his election as WHO’s next Director-General, Dr Tedros
Adhanom Ghebreyesus served as Minister of Foreign Affairs, Ethiopia
from 2012–2016 and as Minister of Health, Ethiopia from 2005–2012.
He has also served as chair of the Board of the Global Fund to Fight
AIDS, Tuberculosis and Malaria; as chair of the Roll Back Malaria
(RBM) Partnership Board; and as co-chair of the Board of the Partnership for Maternal, Newborn and Child Health.
As Minister of Health, Ethiopia, Dr Tedros Adhanom Ghebreyesus led a comprehensive reform effort of the country’s health system,
including the expansion of the country’s health infrastructure, creating 3500 health centres and 16,000 health posts; expanded the health
workforce by 38,000 health extension workers; and initiated financing mechanisms to expand health insurance coverage. As Minister of
Foreign Affairs, he led the effort to negotiate the Addis Ababa Action
Agenda, in which 193 countries committed to the financing necessary
to achieve the Sustainable Development Goals.
As Chair of the Global Fund and of RBM, Dr Tedros Adhanom
Ghebreyesus secured record funding for the two organizations and created the Global Malaria Action Plan, which expanded RBM’s reach
beyond Africa to Asia and Latin America.

tional cooperation to achieve GVAP goals.
It requests the WHO Secretariat to
continue supporting countries to achieve
regional and global vaccination goals. It
recommends scaling up advocacy efforts to
improve understanding of the value of vaccines and of the urgent need to meet the
GVAP goals. The Secretariat will report
back in 2020 and 2022 on achievements
against the 2020 goals and targets.
Immunization averts an estimated 2 to 3

million deaths every year from diphtheria,
tetanus, pertussis (whooping cough), and
measles. An additional 1.5 million deaths
could be avoided if global vaccination coverage were improved.
Refugee and migrant health
Delegates asked the Director-General to
provide advice to countries in order to promote the health of refugees and migrants,
and to gather evidence that will contribute

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H E A L T H I 33

The 70th World Health Assembly

to a draft global action to be considered at
the 72nd World Health Assembly in 2019.
They also encouraged Member States to
use the framework of priorities and guiding
principles to promote the health of refugees and migrants developed by WHO, in
collaboration with IOM and UNHCR, to
inform discussions among Member States
and partners engaged in the development
of the UN global compact on refugees and
the UN global compact for safe, orderly and
regular migration.
There are an estimated 1 billion migrants in the world – one in seven of the
world’s population. This rapid increase
of population movement has important
public health implications, and requires
an adequate response from the health sector. International human rights standards
and conventions exist to protect the rights
of migrants and refugees, including their
right to health. But many refugees and migrants often lack access to health services
and financial protection for health.
Health problems faced by newly-arrived
refuges and migrants can include accidental
injuries, hypothermia, burns, cardiovascular
events, pregnancy and delivery-related complications. Women and girls frequently face
specific challenges, particularly in maternal,
newborn and child health, sexual and reproductive health, and violence. Children are
prone to acute infections such as respiratory
infections and diarrhoea because of poor
living conditions and deprivation during
migration and forced displacement. Lack of
hygiene can lead to skin infections.
Refugees and migrants are also at risk of
psychosocial disorders, drug abuse, nutrition disorders, alcoholism and exposure to
violence. Those with noncommunicable
diseases (NCDs) can also suffer interruption of care, due either to lack of access or
to the decimation of health care systems
and providers.
Substandard and falsified medical products
“Substandard” medical products (also
called “out of specification”) are authorized
by national regulatory authorities, but fail
to meet either national or international
quality standards or specifications – or in
some cases, both. “Falsified” medical products deliberately or fraudulently misrepresent their identity, composition or source.
The Assembly also agreed a definition of

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“unregistered or unlicensed medical products”. These have not been assessed or approved by the relevant national or regional
regulatory authority for the market in which
they are marketed, distributed or used.
The new terminology aims to establish
a common understanding of what is meant
by substandard and falsified medical products and to facilitate a more thorough and
accurate comparison and analysis of data.
It focuses solely on the public health implications of substandard and falsified
products, and does not cover the protection of intellectual property rights.
Substandard and falsified medical products can harm patients and fail to treat
the diseases for which they were intended.
They lead to loss of confidence in medicines, healthcare providers and health systems, and affect every region of the world.
Anti-malarials and antibiotics are amongst
the most commonly reported substandard
and falsified medical products, but all types
of medicines can be substandard and falsified. They can be found in illegal street
markets, via unregulated websites, and in
pharmacies, clinics and hospitals.
Delegates agreed to adopt the new name
of “substandard and falsified” (SF) medical products for what have until now been
known as “substandard/spurious/falsely-labelled/falsified/counterfeit (SSFFC)” medical products.
The world drug problem
Delegates agreed on the need for intensified efforts to help Member States address
the world drug problem. They asked the
WHO Secretariat to strengthen its collaboration with the United Nations Office
on Drugs and Crime and the International
Narcotics Control Board to implement
the health-related recommendations in
the outcome document of the 2016 Special Session of the United Nations General Assembly on the world drug problem
(UNGASS).
It has been 26 years since the Health Assembly made a decision on this topic. The
Secretariat is asked to report back on progress in 2018, 2020 and 2022.
According to WHO’s latest estimates,
psychoactive drug use is responsible for
more than 450,000 deaths each year. The
drug-attributable disease burden accounts
for about 1.5% of the global burden of dis-

H E A L T H

ease. Furthermore, injecting drug use accounts for an estimated 30% of new HIV
infections outside sub-Saharan Africa and
contributes significantly to hepatitis B and
C epidemics in all regions.
Childhood obesity
Delegates welcomed a plan to implement
recommendations made by the WHO
Commission on Ending Childhood Obesity. The recommendations aim to reverse
the rising trend of children and adolescents becoming overweight and obese.
The implementation plan highlights the
importance of tackling environments
that facilitate access to and promotion
of unhealthy foods and make it hard for
children to be physically active. It focuses
on preventing obesity throughout the life
course, from the earliest years.
The implementation plan aims to help
countries to fulfil commitments on addressing obesity that they have already made.
These include pledges contained in the
WHO global action plan for the prevention
and control of NCDs, the comprehensive
implementation plan for maternal, infant
and young child nutrition and as part of the
2030 Agenda for Sustainable Development.
The implementation plan stresses encouraging infants and young children to choose
healthy foods through supportive policies
and interventions, including taxation, marketing and labelling. The plan focuses on
supporting and building healthy habits that
last through the life course. It also highlights
the need for shaping school environments
and curricula as well as community environments to support healthy lifestyle choices –
including the taking of physical exercise.
The plan includes recommendations
on interventions to treat overweight and
obesity in children, plus measures to prevent unhealthy weight gain in infants and
young children.
Pandemic Influenza
Delegates reaffirmed the critical role played
by the Pandemic Influenza Preparedness
Framework’s (PIP) as a specialized international instrument that facilitates expeditious access to influenza viruses of human
pandemic potential, risk analysis and the
expeditious, fair and equitable sharing of
vaccines and other benefits.
They emphasized the importance of pri-

WHO/L. Cipriani

Winners of the 2017 public health awards receive their prizes at the World Health Assembly.

Recognition for accomplishments in public health
International action by Cuba to support emergencies, including disease outbreaks such as Ebola – and lifelong dedication to reducing
the hepatitis burden in Mauritania and Mongolia – gain recognition on the world health stage.
The prizes, established in the name of eminent health professionals, are awarded for accomplishments in public health. Every year,
national health administrations and former prize recipients submit
nominations. The WHO Executive Board, in its January session,
designates the winners based on recommendations made by the selection panel of each foundation awarding a prize.
This year’s winners were presented with their awards on 26 May during the plenary meeting of the Seventieth World Health Assembly.
The United Arab Emirates Health Foundation Prize of
US$20,000 went to Professor Lô Boubou Baïdy, 61, of Mauritania,
for his significant contribution to the establishment of the national
blood transfusion centres and laboratory services , as well as his
fight against viral hepatitis, HIV/AIDS and other sexually transmitted infections.
oritizing and supporting global pandemic
influenza preparedness and response, including through the strengthening of
domestic seasonal influenza virus surveillance, manufacturing and regulatory capacities and international coordination
and collaboration through the Global Influenza Surveillance and Response System
(GISRS) to identify and share influenza
viruses with pandemic potential rapidly.
The Health Assembly agreed that the
WHO secretariat should comprehensively analyse, in consultation with Member
States and relevant stakeholders, including the GISRS, the implications of
amending the definition of PIP biological materials to include genetic sequence
data and expanding the PIP Framework
to include seasonal influenza. The delegates further agreed that the PIP Framework model has potential to be used for
other pathogens.
The PIP Framework was set up in 2011
to introduce greater equity and solidarity
among nations when the next pandemic

The 2017 Sasakawa Health Prize of $30,000 for outstanding
innovative work in health development, has been awarded to Dr
Rinchin Arslan for his remarkable lifelong contribution to the advancement of primary health care in Mongolia and specifically his
work in fighting viral hepatitis.
The Dr Lee Jong-wook Memorial Prize for Public Health of
$100,000 was awarded to the Henry Reeve International Medical
Brigade (Cuba).
Established in 2005 by more than 1500 Cuban health professionals, the Henry Reeve Brigade is integrated into the medical cooperation unit of the Ministry of Public Health of Cuba.
Cuba’s international medical emergency response experience began over 40 years before the establishment of the Henry
Reeve Brigade, when physicians and nurses trained in disaster
medicine and infectious disease containment, were dispatched
to Chile in 1960 after a catastrophic earthquake. This marked
the beginning of Cuba’s internationalist outlook and health cooperation.

strikes. The PIP Framework provides
WHO with real-time access to approximately 10% of global vaccine production,
enabling the Organization to send life-saving doses to developing countries in need.
Health Workforce
The Health Assembly agreed to a five-year
action plan under which WHO will collaborate with the International Labour
Organization, and the Organization for
Economic Cooperation and Development
in working with governments and key
stakeholders to address the global health
and social workforce shortfall and contribute to international efforts to achieve the
Sustainable Development Goals.
The plan calls on countries to view the
health and social workforce as an investment, rather than a cost, and take advantage of the economic benefits of growth
in the health and social sector. It outlines
how ILO, OECD and WHO will take intersectoral action on five fronts: galvanizing political support; strengthening data

and evidence; transforming and scaling
up the education, skills and decent jobs
of health and social workers; increasing
resources to build the health and social
workforces; and maximizing the multiple
benefits that can be obtained from international health worker mobility.
It also focuses on maximizing women’s
economic empowerment and participation. It addresses occupational health
and safety, protection and security of the
health and social workforce in all settings.
It also covers the reform of service models
towards the efficient provision of care, particularly in underserved areas.
The action plan supports the WHO
Global Strategy on Human Resources for
Health: Workforce 2030. It will facilitate
implementation of the recommendations
of the United Nations Secretary General’s High-Level Commission on Health
Employment and Economic Growth,
which found that, as populations grow
and change, the global demand for health
workers will double by 2030.

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Paediatrics

Celiac disease affects the lining of the intestine

Future treatment modalities
in Celiac Disease

By Dr Rajeev Tomar

Celiac Disease (CD) is an immune-mediated systemic disorder elicited by gluten
and related prolamines in genetically susceptible individuals and characterized by
the presence of a variable combination of

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gluten-dependent clinical manifestations,
CD-specific antibodies, HLA-DQ2 or
HLA-DQ8 haplotypes, and enteropathy.
CD-specific antibodies comprise autoantibodies against TG2, including endomysial
antibodies (EMA), and antibodies against
deamidated forms of gliadin peptides
(DGP).
This is a serious issue in children, as
undiagnosed celiac disease can lead to
growth retardation, anaemia, etc. Moreover, people with celiac disease have
genes that also predispose them to other
autoimmune disorders, like autoimmune
thyroiditis. Having one autoimmune
condition increases the chances of having another autoimmune condition. Furthermore, it has been suggested that the
chance of developing other autoimmune
disorders is increased, when diagnosis of
coeliac disease is delayed, hence all chil-

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dren with CD are screened on an annual
basis for other autoimmune diseases.

Pathogenesis
Gluten is a general term used to describe a
mixture of wheat storage proteins (prolamins and glutenins). However other cereals
have proteins that exert a toxic effect for
CD patients; toxic prolamins include gliadin
in wheat, secalin in rye and hordein in barley. These protein domains are resistant to
degradation by gastric, pancreatic and proteases in the human intestinal brush border
membrane thereby allowing them to remain
intact within the intestinal lumen after ingestion. In individuals with CD, these peptides then enter the lamina propria, triggering chronic inflammatory changes. Gliadin
peptides cross the intestinal barrier by both
active transport (transcellular) processes and
via paracellular mechanisms.

It is notable that gliadin peptides in their
native form are not toxic. In order for gluten peptides to cause inflammation, they
must first be altered by the enzyme tissue
transglutaminase (tTG) which is normally
present in nearly all organs and is increased
in areas of inflammation. In the submusosa of the intestine, tTG deamidates gluten peptides, changing peptide shape and
charge. These altered gluten peptides are
then able to bind tightly to HLA-DQ2 and
HLA-DQ8 molecules on antigen-presenting cells. This binding triggers an inflammatory reaction causing lymphocyte infiltration, villous atrophy and the production
of antibodies to gliadin and tTG.

Treatment
Standard current treatment is a gluten
free diet for life. However, approximately
7-30% of patients fail to respond to a gluten-free diet. This may result from either
inadvertent or intentional eating of foods
containing gluten. Moreover, nonglutencontaining grains are not fortified as wheat
flour is. As a result, patients on a glutenfree diet for 10 years or more were shown
to be deficient in vitamins. This has led

Study finds Celiac
Disease and Anorexia
Nervosa diagnoses linked
A large-scale study in May 2017 Pediatrics suggests patients diagnosed with Celiac Disease, an inflammatory digestive disorder triggered by gluten, before age 19 were 4.5 times more likely to have
previously been diagnosed with Anorexia Nervosa.
The study (published online April 3) looked at 17,959 women
whose celiac disease was confirmed with biopsies in Sweden between 1969 and 2008.
Researchers also found that adults previously diagnosed with Celiac
Disease had double the rate of subsequently developing anorexia nervosa, a disorder in which patients severely limit the amount of food
they eat. The researchers said several factors may contribute to the apparent bidirectional association between the two disorders. One is that
patients with celiac disease might have been inaccurately diagnosed
with Anorexia Nervosa, or vice versa, because chronic gastrointestinal
problems and disordered eating patterns may be closely tied.
They said the positive association between the two diseases
should spur a careful initial assessment and follow-up of patients
with these illnesses.
l doi: 10.1542/peds.2016-4367

to research in new non-dietary treatment
modalities for patient with CD.
New possible future treatment
modalities
Emerging research for the treatment of
celiac disease has focused on three areas:
To decrease gluten exposure, to modify intestinal permeability and to modulate immune activation
1. To decrease gluten exposure – This
could be achieved with genetically engineering grains by eliminating immunogenic gluten fragments. However, the
large number of peptide epitopes located
in different genetic loci of the wheat genome makes this approach challenging.
Moreover, potential challenges exist since

the genetic modification of food is controversial and is not regarded favourably by
the public. Another approach is the use of
synthetic polymers that bind and neutralize gliadin. These have recently been studied and experimentally eliminate gliadin.
Enzymatic degradation of the large, immunogenic gliadin peptides into small
nontoxic fragments.
This can be performed by prolyl endopeptidases. These are proteases, found primarily in plants and microorganisms, able
to degrade the Proline-rich gluten peptides
into smaller, less immunogenic fragments.
Alternatively, in recent trial in Italy, selected Probiotic Lactobacilli have the capacity to hydrolyse Gluten Peptides during
simulated gastrointestinal digestion.

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H E A L T H I 37

Paediatrics

Enzyme therapy is attractive; however,
it is complicated because gluten must be
completely prevented from interacting
with the mucosa. Any remaining gluten
peptides may lead to intestinal inflammation
2. To modify intestinal permeability
Intercellular tight junctions are altered in
celiac disease. This could be another therapeutic target used to prevent the migration of luminal gluten peptides across the
intestinal epithelium. Zonulin, an endogenous peptide involved in tight junction
regulation, is amplified in celiac disease
and increases intestinal permeability. AT1001 is a peptide that inhibits the action
of zonulin. Clinical trials have shown no
increase in GI symptoms when challenged
with gluten in patients given AT-1001.
Further phase II studies are currently underway.
3. To modulate immune activation
This may be achieved by preventing gliadin deamination through the inhibition
of tissue transglutaminase, by preventing
HLA presentation through blocking the
HLA DQ2 or DQ8 molecules, or by modulating cytokine production.
(i) BL-7010 is a non-absorbable, orally
available polymer which has a high affinity for gliadins and by sequestering gliadins,
it effectively masks them from enzymatic
degradation and prevents the formation
of immunogenic peptides that trigger the
immune system. This significantly reduces
the immune response triggered by gluten.
BL-7010 is excreted with gliadin from the
digestive tract and does not get absorbed
into the blood. A Phase I/II study with
BL-7010 was successfully completed in
2014. When taken orally, it was demonstrated that it prevents the degradation
of gliadin, which causes the over-reactive
immune response. With gliadin still intact, immune cells are not triggered to
form, which prevents the harmful immune
response those with celiac disease would
usually experience.
(ii) AMG 714 is an investigational
anti-IL-15 monoclonal antibody being studied for the treatment of glutenfree diet non-responsive celiac disease

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(NRCD) and refractory celiac disease.
IL-15 is considered to have a central role
in celiac disease and to be a key driver of
the generation of aberrant and malignant
intraepithelial lymphocytes (IELs).

Vaccine
Nexvax2, a therapeutic vaccine currently in clinical trials, is intended to protect
against the effects of gluten exposure in
HLA-DQ2.5+ patients with celiac disease.
Approximately 90% of celiac disease
patients carry the HLA-DQ2.5 gene.
ImmusanT, the biotech company that
developed the vaccine says, currently,
there is no pharmaceutical treatment for
celiac disease and the only method of
management is to maintain a gluten-free
diet (GFD). Effective implementation of
a GFD is onerous and often impractical.
Persistent intestinal injury and frequent
digestive symptoms in many patients are
evidence of ongoing gluten exposure.
ImmusanT is developing Nexvax2, an
epitope-specific immuno-therapy (ESIT)
that consists of three immunodominant
peptides, designed to protect against gluten exposure.
Phase 1b trials of Nexvax2 were completed in February this year. Phase 2 trials
are planned by ImmusanT.
Mesenchymal stem cells as potential
therapeutic approaches in celiac disease
The emerging area of cellular therapy
for CD is mainly base on the stem cell
therapy, which has the advantage of
targeting multiple pathways. All the
differentiated epithelial cells of the
intestine derived from a single intestinal stem cell (ISC) (CD133+/Lgr5+
crypt cell) compartment which resides at the crypt base. Mesenchymal
stem cells (MSCs) are multi-potent
stromal cells that can differentiate
into a variety of cell types. More studies are required to study further methodological variables such as the route,
doses and intervals of administration,
etc. for the best approach before therapeutic prospect of using MSCs as the
clinical therapy.

Smartphones: small size, big problem
Research has shown that when children watch too much television, their risk of obesity increases. However, more and more
screen time is coming from other devices, like tablets and
smartphones, and the impact of these devices has not been
researched as much. In a new study published in The Journal of
Pediatrics, researchers found that children who reported spending more time on screen devices and watching television engaged in behaviours that can lead to obesity.
Dr Erica L. Kenney and Dr Steven L. Gortmaker from the
Harvard T.H. Chan School of Public Health studied data from
the 2013 and 2015 waves of the Youth Risk Behavior Surveillance System, which included 24,800 adolescents in grades
9-12. The survey gathered data on the following: hours spent
on screen devices (including smartphones, tablets, computers,
and videogames) and watching television, hours of sleep on
an average school night, number of sugar-sweetened beverages
consumed in the previous 7 days, and frequency of physical
activity (at least 60 minutes per day) for the past 7 days.
The researchers found that almost 20% of US adolescents

spent more than 5 hours a day on smartphones, tablets, computers, and videogames compared with only 8% watching
more than 5 hours a day of television. Watching too much
television continued to be associated with obesity and poor
diet among adolescents. However, the researchers also found
that adolescents who spent more than 5 hours a day on screen
devices were twice as likely to drink a sugary drink each day
and not get enough sleep or physical activity, and were about
43% more likely to have obesity compared with adolescents
who did not spend time on these devices.
Although this study cannot conclude definitively that using
screen devices is causing higher rates of obesity, the findings
are cause for concern. According to Dr Kenney: “This study
would suggest that limiting children’s and adolescents’ engagement with other screen devices may be as important for health
as limiting television time.”
Until more research is done, clinicians may want to encourage families to set limits for both television and other screen
devices.

The next 7 great achievements
from paediatric research
Advances in pediatric research have significantly reduced deaths and improved
the quality of life for families worldwide
over prior decades. Researchers are now
poised to achieve even greater medical
accomplishments, buoyed by the use of
new technology-based tools, including
electronic health records that will assist
in longitudinal data collection, according
to an article published by the American
Academy of Pediatrics (AAP).
“The Next Seven Achievements in Pediatric Research,” published in the May
2017 Pediatrics, reflects on the progress
that has been made and predicts the next
great research breakthroughs for children’s
health. The article emphasizes the need
for continued federal support and focus on
child health research. Emerging new risks
such as the Zika virus, obesity epidemic
and exposure to adverse childhood experiences threaten to shorten the lifespans
of the next generation without a sciencebased approach, the authors state.
“We must continue the momentum that

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has brought us life-saving immunizations,
reduced infant deaths and increased life
expectancy for children because of newly
discovered treatments and preventive
measures,” said Tina Cheng, MD, MPH,
FAAP, lead author. “We are on the edge
of exciting new initiatives that can move
forward only with support for research,
physician training and data collection improvements.”
In 2015, the AAP Committee on Pediatric Research highlighted seven great
achievements in paediatric research,
which were chosen from responses to a
survey of paediatric professional organization board members. The seven success
stories cited were: preventing disease with
life-saving immunizations; reducing sudden infant death with a “Back to Sleep”
campaign; finding a cure for Acute Lymphoblastic Leukemia; helping premature
babies breathe with a specific therapy
called surfactant; preventing Human Immunodeficiency Virus transmission from
mother to baby; increasing the life expec-

H E A L T H

tancy for children with Sickle Cell Anaemia and Cystic Fibrosis; and saving lives
with car seats and seat belts.
The next seven great achievements, the
authors predict, will be:
• More paediatric immunizations to
prevent emerging and persistent diseases
• Cancer immunotherapy
• Genomic discoveries to predict, prevent and more effectively treat disease
• Recognizing foetal and childhood origins of adult disease before effective early
intervention
• Understanding how social and environmental conditions affect health to
guide population health efforts
• Quality improvement initiatives in
medical care
• Implementation of research knowledge to reduce global poverty
Yet the paediatric research field faces
challenges, such as the unique effort needed to include children and teens in clinical
research.
l doi: 10.1542/peds.2016-3803

Mr Tom Quick of
the Royal National
Orthopaedic
Hospital is an
expert in the
treatment of Erbs
Palsy or Birth
Brachial Plexus
Palsy (BBPP)

The surgeons at the Royal National Orthopaedic Hospital (RNOH) Peripheral
Nerve Injury Unit (PNI), Mr Tom Quick
and his colleagues, Dr Marco Sinisi and Mr
Mike Fox, offer a full range of treatment
options for the injury known as Erbs Palsy
or Birth Brachial Plexus Palsy (BBPP).
Their service is focused on a functional
improvement for the patient from birth,
through adolescence to adulthood.
Wilhelm Heinrich Erb was a Bavarian
nerve doctor of the late 19th Century. He
gave his name to an injury of the nerves of
the brachial plexus which happens at the
time of birth: Erb’s Palsy. There is much we
have learnt about this injury since then.
The nerves of the arm leave the spine
at five levels (like floors of a building).
These nerve ‘roots’ are made up of hundreds of thousands of nerve cells which
then all intermingle at a major junction
called the brachial plexus. The injury of
a Birth Brachial Plexus Palsy (BBPP) is
one of the stretching forces of the delivery. Nerves can cope with some stretch
but too much damages them. The damage can be quite mild (conduction block)
which can recover completely and quite
quickly, or be partially or completely
snapped (rupture) or pulled clean from
the spinal cord (avulsion).

The nerve injury in BBPP
Alongside precise and expert examination of the child I also use neurophysiology to make this assessment. Neurophysiology is medical circuit testing. This study
is able to provide information not just on
the condition of the nerves but also on
how likely they are to recover.
Primary Brachial Plexus surgery
This is an operation on the nerves of the
brachial plexus in the neck to free them
from the scar tissue which forms after the
nerves are damaged. Then if necessary I
might have to take spare nerves from the
child’s arm or leg and splice them (nerve
grafting) into the brachial plexus or reroute (nerve transfer) some other undamaged nerves from nearby.
The most important feature to understand about nerve surgery is that it is not
like rewiring a light bulb: But more like
planting a vine – it has to grow and it does
this slowly. Surgery allows recovery to take
place it doesn’t actually repair the function
of the nerves directly. Following nerve surgery there is often no sign of improvement
for many months and full improvement
not for a number of years after surgery.
The damage of the nerves is one problem, but this problem always leaves im-

balance in the function of the muscle, the
growth of the bones and muscles and the
way the body learns to use the arm, thus it
can continue to cause problems throughout all of childhood.
The shoulder in BBPP
The most common problem in BBPP is
one that affects the shoulder; the problem of shoulder dysplasia. This condition
leads to a series of events that leads to
shoulder joint subluxation and then full
dislocation of the shoulder joint. At the
RNOH the PNI unit is highly experienced in an operation called an anterior
release, which corrects and rebalances the
early stage of the problem. Later presenting cases (over age 4-6) often require an
operation which was developed here at
the RNOH called a glenoplasty where the
bone of the shoulder joint is reshaped to
improve function.
The forearm and hand
In BBPP there is often involvement of
the arm further down than the shoulder
and elbow. Joint releases, tendon transfers, nerve transfers, osteotomies are all
utilised in specific cases.
■ Private patient enquiries can be made
via the website: www.rnohppu.com

M I D D L E

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H E A L T H I 41

Paediatrics

Precarious beginning
leads to promising future
Nemours duPont CT Surgeon, Dr. Christian Pizarro,
performs lifesaving surgery
At 34 weeks and 1 day, Felice Curley
delivered beautiful twin boys. Tyrus (Twin
A) and Hezakiah (Twin B) weighed in at
4.7 lbs and 4.9 lbs, respectively. In the
neonatal intensive care unit (NICU)
at their local community hospital, the
preemies received the special care and
attention they needed.
However, after a few days, Hezakiah, still
in the NICU, began exhibiting breathing
difficulty. The clinicians caring for Hezakiah
were convinced that he had developed
some type of pulmonary condition and
began a series of different treatments to
ameliorate the symptoms. Unfortunately,
these interventions failed and Hezakiah
began deteriorating rapidly. He was quickly
transferred to a larger medical center for
care. Once Hezakiah arrived at the facility,
the providers there quickly realized they
were not equipped to properly help this very
sick infant. Because of this, preparations
were made to transfer Hezakiah to Nemours/
Alfred I. duPont Hospital for Children,
a tertiary care center. Though 80 miles
away, it was clear to medical personnel that
transporting Hezakiah there was the only
way to save his life.
While in transit, Hezakiah was put on
life-sustaining ECMO by the Nemours
Transport Team. Upon arriving at
Nemours/Alfred I. duPont Hospital for
Children, Hezakiah was transferred to
the NICU. In the NICU, pulmonary
etiology was ruled out. It was determined
that Hezakiah had a complex cardiac
abnormality. Hezakiah was diagnosed
with a rare congenital cardiac condition
called Total Anomalous Pulmonary
Venous Return/Repair (TAPVR). This
heart defect occurs in the first eight
weeks of pregnancy and causes the vessels

42 I M I D D L E

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that bring oxygen-rich blood back to the
heart from the lungs to be improperly
connected. Babies with this heart
defect can’t supply oxygenated
blood to the body after birth.
Instead, they will have a
mixture of oxygenated and
de-oxygenated blood in
circulation – a situation
that is fatal.
More
specifically, in TAPVR,
the four pulmonary veins
do not connect normally
to the left atrium.
Instead, the pulmonary
veins drain abnormally
to the right atrium through
an abnormal connection.
At approximately 22 days old,
Hezakiah needed heart surgery to
live. According to the team at Nemours/
Alfred I. duPont Hospital for Children,
the chances of Hezakiah surviving the
surgery were less than 50%. Despite
the odds, Dr. Christian Pizarro, a worldrenowned pediatric cardiothoracic surgeon
at Nemours/Alfred I. duPont Hospital
for Children, surgically reconnected
the pulmonary veins to the left atrium.
While Hezakiah recovered in the CICU,
the transport team who brought him to
Nemours/Alfred I. duPont Hospital for
Children, and who kept him alive on that
trip, stopped by to check on him.
Felice Curley was astounded by the
outpouring of care and concern her family
received. She commented: “Long after the
surgery was done, Dr. Pizarro continued
to check in on my son, always taking the
time to answer my questions and always
genuinely interested in us as a family.
That’s what has made my experience

H E A L T H

Dr. Christian
Pizarro holds
baby Curley

great. It’s the whole team here. The social
worker, psychologist, speech therapist,
the transport team, the nutritionist, and
child life who consoled and helped my
two older children to understand what
had happened to their brothers. And, of
course, without Dr. Pizarro’s expertise,
my son wouldn’t be here. I think this
[Nemours/Alfred I. duPont Hospital for
Children] is the greatest hospital!”
Now at 12 weeks old, Tyrus weighs in
at a robust 10 lbs, and Hezakiah isn’t far
behind at 7 lbs, 14 oz. He’s learning how
to suck so that he can gain weight more
quickly and get stronger. Felice Curley
says he is progressing nicely with the help
of a speech therapist and other therapy
services experts.
Thanks in large part to the expertise and
support of the entire team at Nemours/
Alfred I. duPont Hospital for Children,
Hezakiah has a bright future ahead.

Screening MRI benefits women
at average risk of breast cancer
MRI screening improves early diagnosis
of breast cancer in all women – not only
those at high risk – according to a new
study from Germany published online in
the journal Radiology.
MRI has long been known as an effective breast cancer screening modality that
offers better sensitivity than mammography and ultrasound. Currently, guidelines
reserve breast MRI screening for women
who have a strong family history or other
specific breast cancer risk factors. MRI
screening has not been considered necessary for women at average risk, and there
has been resistance to expansion of MRI
into this population due, in part, to concern over higher costs.

44 I M I D D L E

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However, with breast cancer remaining
a major cause of cancer death in women,
there is good reason to pursue the search
for improved screening methods, according to the study’s lead author, Christiane
Kuhl, M.D., chair of the Department of
Radiology at RWTH Aachen University
in Aachen, Germany.
Between 2005 and 2013, Dr Kuhl and
colleagues studied breast MRI’s impact on
2,120 women, ages 40 to 70, with less than
a 15% lifetime risk of breast cancer. The
women had normal screening mammograms
and, in the case of those with dense breast
tissue, normal screening ultrasound. Breast
MRI detected 60 additional breast cancers,
including 40 invasive cancers, for an over-

H E A L T H

all supplemental cancer detection rate of
15.5 per 1,000 women. Of the 60 cancers
detected in the study group over the observation period (7,007 screening rounds), 59
were found only using MRI, one was found
also by mammography, and none by mammography or ultrasound alone.
According to Dr Kuhl, the results suggest
that MRI can serve as a useful supplemental
screening tool for women at average risk,
especially those with dense mammographic
tissue, and that MRI is superior to supplemental ultrasound for this purpose.
The results also highlight the ability of
MRI in the detection of more aggressive
types of cancer.
“The faster a cancer grows and the bet-

Neuroimaging technique
may predict autism
among high-risk infants

Christiane Kuhl, M.D.

ter it is in seeding metastases, the better will it be picked
up early by MRI,” Dr Kuhl said. “In our cohort, cancers
found by MRI alone exhibited features of rapid growth at
pathology.”
This ability is especially important in women with dense
breast tissue in which aggressive cancers may be missed on
mammography. Left undetected, these cancers will grow
to become clinically palThe results
pable cancers, also known
as interval cancers. The
suggest that
new study showed that,
MRI can serve
consistent with previous
as a useful
research, breast MRI can
supplemental
depict these rapidly growing cancers with high reliscreening tool for
ability.
women at average
According to Dr Kuhl,
risk, especially
interval cancers exhibit
those with dense
an adverse biologic profile
and are the main driver of
mammographic
breast cancer mortality.
tissue, and that
Additional cancers deMRI is superior
tected by MRI screening
to supplemental
in the study had a skewed
distribution towards a
ultrasound for
higher-than-normal prevthis purpose.
alence or incidence of rapidly growing (grade 3) cancers.
“The interval cancer rate in our study was zero percent. Not a single cancer was undetected that became
palpable,” she said. “This suggests that MRI finds breast
cancers that also mammography would find, but MRI detects them earlier, and it finds the cancers which, if MRI
had not been done, would have progressed to interval
cancers.”
l doi: 10.1148/radiol.2016161444

Functional connectivity magnetic resonance imaging (fcMRI)
may predict which high-risk, 6-month old infants will develop autism spectrum disorder by age 2 years, according to a study funded
by the Eunice Kennedy Shriver National Institute of Child Health
and Human Development (NICHD) and the US National Institute of Mental Health (NIMH), two components of the National
Institutes of Health. The study is published in the June 7, 2017,
issue of Science Translational Medicine.
In the United States autism affects roughly 1 out of every 68
children. Siblings of children diagnosed with autism are at higher
risk of developing the disorder. Although early diagnosis and intervention can help improve outcomes for children with autism,
there currently is no method to diagnose the disease before children show symptoms.
“Previous findings suggest that brain-related changes occur in
autism before behavioural symptoms emerge,” said Diana Bianchi,
M.D., NICHD Director. “If future studies confirm these results, detecting brain differences may enable physicians to diagnose and
treat autism earlier than they do today.”
In the current study, a research team at the University of North
Carolina at Chapel Hill and Washington University School of
Medicine in St. Louis focused on the brain’s functional connectivity -- how regions of the brain work together during different tasks
and during rest. Using fcMRI, the researchers scanned 59 highrisk, 6-month-old infants while they slept naturally. The children
were deemed high-risk because they have older siblings with autism. At age 2 years, 11 of the 59 infants in this group were diagnosed with autism.
The researchers used a computer-based technology called machine learning, which trains itself to look for differences that can
separate the neuroimaging results into two groups -- autism or nonautism -- and predict future diagnoses. One analysis predicted each
infant’s future diagnosis by using the other 58 infants’ data to train
the computer program. This method identified 82% of the infants
who would go on to have autism (9 out of 11), and it correctly
identified all of the infants who did not develop autism. In another
analysis that tested how well the results could apply to other cases,
the computer program predicted diagnoses for groups of 10 infants,
at an accuracy rate of 93%.
“Although the findings are early-stage, the study suggests that in
the future, neuroimaging may be a useful tool to diagnose autism
or help health care providers evaluate a child’s risk of developing
the disorder,” said Joshua Gordon, M.D., Ph.D., NIMH Director.
Overall, the team found 974 functional connections in the
brains of 6-month-olds that were associated with autism-related
behaviours. The authors propose that a single neuroimaging scan
may accurately predict autism among high-risk infants, but caution
that the findings need to be replicated in a larger group.
l doi: 10.1126/scitranslmed.aag2882 (2017)

M I D D L E

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H E A L T H I 45

The University of Manchester

Middle East healthcare needs to develop
leadership to meet the four major
challenges facing the international industry

By Dr Stephen Brookes

The Middle East healthcare sector is vibrant and active, and continues to attract
investment as private and public-sector
investors build the new capacity needed to
serve a growing population of citizens and
residents, and international healthcare
tourists.
The global industry still faces a number
of challenges; the first and foremost, according to the World Economic Forum, is
the spiraling cost of healthcare delivery,
which is reaching unsustainable levels.
With the rising cost comes the need to
transform the industry and improve efficiencies, patient outcomes, and financial
sustainability. Success factors include sharing and learning from international practice and experience, global perspectives,
and individual and collective leadership.
Healthcare is arguably the world’s largest industry and is transforming rapidly.
Healthcare systems are being continuously
modernized and reformed, whether public, private or hybrid systems. The need
to demonstrate improved outcomes will
continue. Transformational change will
be needed more than ever, with a focus on
health outcomes based on an evidencebased approach.
With changing demographics and new

46 I M I D D L E

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technologies, leaders will need to be more
adaptive and prepared to be creative and
opportunistic, within an appropriate risk
assessment climate. These issues present
a significant leadership challenge within
healthcare systems.
The opportunity to learn from other systems offers real benefits to healthcare leadership, in equipping leaders and managers with
cutting-edge knowledge and practice from
around the world whilst retaining a strong
emphasis on regional, national and local systems and practices, putting the patient at the
heart of all that healthcare leaders do.
Healthcare leadership exists at multiple
levels with each level defining the type of
leadership required through a collective
vision. It is most certainly collective at the
level of the patient, as often the health and
well-being of the carers and nuclear family
depends on this.
Collective leadership must build the capacity and capability of the people within
the healthcare system through improved
skills and the development of appropriate
behaviours. The focus should be on how
you lead within a collective healthcare system, always putting the patient first.
Given the global nature of healthcare
leadership, leaders need to adapt to changing markets and the potential for change
in a complex and uncertain world.
Leaders who are unable to do this will remain rooted in the traditional form of leadership and continue to face difficulties currently associated with cost, quality and access,
with patients isolated from the leadership
decisions and practices. The concept of the
patient ‘as leader’ is starting to emerge.
There are four major global leadership
challenges faced by healthcare systems
across the world: Universal access to different levels of healthcare in a timely, costeffective and seamless manner; giving prevention as much priority as treatment and
recognising long term benefits; delivering

H E A L T H

The University of
Manchester’s new parttime MSc International
Healthcare Leadership
addresses four global
healthcare leadership
challenges.
healthcare across a range of public/private
and hybrid systems, and; integrating care
across diverse primary, secondary and tertiary providers.
In the GCC, there are many similarities
in the healthcare systems of member states,
but there are also differences. The balance
between public and private provision of
healthcare is one such difference, although
they are ultimately working towards a common standard of health and well-being.
In a complex healthcare environment,
leaders need to focus at different levels.
This forms the basis of a unique international leadership master’s programme
where the learning will help leaders
achieve this.
The University of Manchester’s new
part-time MSc International Healthcare
Leadership addresses these four global
healthcare leadership challenges, and
concentrates on applying learning to the
practice of healthcare leadership and service improvement focusing always on evidence-based outcomes.
The Author
Dr Stephen Brookes is senior fellow in
public policy and management and specialises in leadership and organisational
development with a special focus on
healthcare management, The University
of Manchester

Emirates Hospital / CosmeSurge

CosmeSurge works closely with Emirates
Hospital for the treatment of breast cancer
CosmeSurge cooperates daily with Emirates
Hospital specialists who are part of their
Breast Program. Dr Dora Evangelidou, the
Plastic and Reconstructive Surgeon at CosmeSurge, said: “It is shown by many studies
that the basis of excellence in breast cancer
treatment and recovery is the care given by
a multidisciplinary team.”
“When a patient needs a removal of the
breast or even breast conserving surgery, in
most cases we offer immediate reconstruction using techniques tailored to the individual. Our breast surgeons cooperate with
plastic-reconstructive surgeons to get the
best cosmetic results,” he said.
“Breast reconstruction, frequently begins at the time of removal of the breast.
In our hands, each patient discusses her reconstructive options with her plastic surgeon before surgery. Our policy at CosmeSurge and Emirates Hospital is to ensure
complete awareness of breast reconstruction options and this can be achieved with
a single visit to our Plastic and Reconstructive Surgery department. Our breast
surgeon and our reconstructive surgeon
will then make a coordinated plan for each
patient’s treatment.”
Usually, the two main choices are between using the patient’s own tissue for reconstruction or using implants. Frequently
implant reconstruction is performed in two
stages starting with an expander at the time
of removal of the breast. Less frequently and
if a small breast is desired, a permanent implant is placed at the time of the removal of
the breast.
“We always advise patients to see a plastic
surgeon about reconstruction as soon as she
considers treatment that includes the possibility of surgery to remove a breast. It is also
possible to see a plastic surgeon after they
have begun or even completed treatment
for breast cancer. However, some options
are best if carried out with cooperation between the surgeon who removes the breast
and the surgeon who will begin reconstruction at the time of removal of the breast.”
Dr Evangelidou added: “Often when we
hear about plastic surgery, we think of cosmetic procedures such as tummy tuck and

Dr Dora Evangelidou

Dr Serife Simsek

breast augmentation, but it should be remembered that the field of plastic surgery also
focuses on reconstruction. Actually, reconstructive plastic surgery is the root and the

backbone of what we know today as cosmetic
surgery. It is really impressive how a simple
reconstructive procedure has the power to
improve a life. That is indeed priceless.”

Breast cancer
Breast cancer is the most common cancer in women. One in eight women will be
diagnosed with breast cancer over the course of her lifetime. Breast cancer which
is diagnosed in the early stages can be treated successfully. A woman’s risk of breast
cancer increases if she has a first-degree relative (mother, sister, daughter) who has
breast cancer history.
About 5-10% of breast cancers can be linked to gene mutations (abnormal changes) inherited from one’s mother or father. Mutations of the BRCA1 and BRCA2
genes are the most common. About 85% of breast cancers occur in women who have
no family history of breast cancer. Symptoms of breast cancer include: a lump in the
breast, swelling of the breast, skin irritation or dimpling, breast pain, the nipple turning inward, redness or thickening of skin on the breast, a bloody or clear nipple discharge other than breast milk, or a lump in the underarm area.
It’s important to get any changes in the breast diagnosed promptly by a breast surgeon. Early breast cancer diagnosis increases the chance of a successful treatment.
Regular screening, increased awareness helps with this.
Surgery is usually the first-line treatment of breast cancer. The patient and surgeon
decide together on the type of surgery based on the disease stage and tumour characteristics. Breast conserving surgery is also an option in some cases. Chemotherapy and
radiation therapy can be used to destroy cancer cells that may remain in the breast
after surgery. Hormonal therapy is used to treat hormone-receptor-positive breast cancers by reducing the amount of estrogen or blocking its action.

M I D D L E

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H E A L T H I 47

Beyond Borders

The needs right now
and in the future

Dr Khalid Elsheikh, Deputy Programme Manager for Iraq, Syria, Jordan and Turkey, and
Dounia Dekhili, Programme Manager for Iraq, Syria, Jordan and Turkey, are both members of
MSF’s operational cell based in United Arab Emirates, and it’s from there that they manage
some of MSF’s activities in Syria. In early April, they agreed to discuss the way MSF works in
Syria after six years of war, the challenges faced, the changes and the constants.

Question: When were you last in Syria
and what was your objective there?
n Dr Khalid Elsheikh: I was last there
in 2014. I was conducting an explo
(exploratory trip to evaluate the medical
needs) along with two colleagues – a
surgeon and a nurse. The needs were vast,
particularly among internally displaced
people, but it was impossible to act on
them. Every day and every night we were
shelled, it seemed to be targeted. The area
where we stayed, along with the hospital
where we conducted evaluations, had
never come under attack before, and
suddenly there was a period of intense
bombardment in a localised area. We even
moved our accommodation to a new area,
and once again we came under fire from
missiles. It became clear that our presence
put the local population in danger, and we
made the decision to withdraw. I felt lucky
after that – it really was just a matter of
luck that we weren’t hit.
Question: You’ve been to different projects
in Syria a number of times, including
projects in Aleppo and Idlib. Have you ever
witnessed one of the mass casualty events
we see so often in the media?
n Dr Khalid Elsheikh: I’m a General
Practitioner by training and my role in Syria
was as an Emergency Coordinator rather
than as a medical responder. However, I
did witness some mass casualty events, and
during these I took responsibility for triage.
During these events, there were huge
influxes of people, and it was incredibly
crowded. People are desperate in these
times – being responsible for triage can
mean telling people that their loved ones
can’t be treated – desperate families would
bring someone who had already died

48 I M I D D L E

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and insist on their receiving treatment.
When there are so many others who need
urgent attention, we have to continue.
But it’s very difficult trying to explain why
someone can’t be taken to the operating
theatre when their loved ones insist.
Question: What are the primary medical
concerns in Syria right now?
n Dr Khalid Elsheikh: The victims of
war are highlighted in the media – we
are confronted with horrifying images of
people killed and injured in bombings – but
these are the direct victims. We hear very
little about the indirect victims. Currently,
there are huge numbers of people with
chronic diseases without medication; there
are people who are sick, but won’t seek
help as they fear hospitals may be targeted
by military attacks.
Most of the health facilities now
functioning were created in a state of
emergency. As large facilities are so
frequently targeted, medical staff tend
to work in converted shops, houses or
farms. Often we have to work in poor
conditions, with a lack of supplies. The
most vulnerable demographic right now
is women and children, and the lack of
routine vaccination (against preventable
diseases like measles, rubella, tetanus or
pneumonia) is a serious concern. MSF
seems to be the only organisation providing
routine vaccinations right now.
Question: What are the long-term
implications for healthcare in Syria?
n Dr Khalid Elsheikh: We save the
lives we can, but the fact is that people
need more than saving. They need
physiotherapy to help them walk again,
they need reconstructive surgery to help

H E A L T H

Dr Khalid Elsheikh

Dounia Dekhili

them regain mobility and perform everyday
tasks. So many people will now suffer from
disabilities. This new generation growing
up will be particularly vulnerable to
disease, because they simply didn’t receive
the routine vaccinations they needed.
In medical circles, people discuss the
eradication of things like Polio – but that’s
just not realistic when so many young
people will go without the protection they
need. Aside from the physical issues, an
enormous people will now have to live
with post-traumatic stress disorder. They
will have to learn to live, to work and
to interact with others, after witnessing
stunning brutality and widespread carnage.
These things can’t be underestimated.

Question: How does the situation in Syria
compare to working in other armed conflicts?
n Dounia Dekhili: What’s different here
is that we have been forced to stay away
from such a catastrophe, with zero ability
to negotiate humanitarian space, for such
a long period of time. The last time I was
there was in May 2013, visiting two of our
medical facilities in Atma and Qabasin
soon after they were opened. Our project
in Qabasin closed in October 2014. We
had already evacuated the expatriate
team following staff kidnappings by the
so-called ‘Islamic State’ (IS) earlier in the
year. The kidnappings actually occurred
far from Qabasin, but there were so many
armed groups operating at the time, that
it became difficult to tell who was who,
and who it was possible to negotiate with.
Initially it was possible to negotiate with
certain groups, and they gave us space to
work, even IS. But this diminished rapidly,
and we were never able to negotiate with
the government in Damascus. Crossing
the border with Turkey became very
complicated in the summer of 2013. We
withdrew expatriate staff from Atma on
February 2014. Since the evacuation of
expatriate staff, we have relied on working
with our Syrian colleagues through remote
management.
Question: How effective is this remote
management of medical facilities?
n Dounia
Dekhili:
Our Syrian
colleagues are sustaining the projects
remarkably well under the circumstances.
To qualify that statement, it’s important
to understand that the majority of
medical staff now working inside Syria
were not trained to work in a war zone,
but they have had to learn as they work.
This is not ideal, and medical staff at MSF
are usually expected to have a good level
of experience before they even begin
their training for emergency situations.
There is a big difference between
medical work in a secure, well-staffed
and well-equipped environment, and
frontline medical work. So, the fact that
the staff inside Syria continue to save
lives, with remote training, guidance and
assessment, is amazing. However, this
approach comes with problems. Without
being there in person, it’s very difficult
to assess the level of danger our staff
experience. This is extremely frustrating.

This image from October 2016 shows 11-year-old Mohamed who has shrapnel wounds to his head
and body after airstrikes on east Aleppo’s Al Maadi neighbourhood. He had been in hospital for four
weeks, but could not be discharged as his wounds needed to be drained regularly. As a result of
his injury, Mohamed lost awareness of his surroundings and could no longer speak. The surgery he
needed was not available in east Aleppo. (Names have been changed).

Question: Did you ever witness the trauma
we hear so much about in the media?
n Dounia Dekhili: I remember when
the hospital in Atma first opened – we
could hear the shelling. At that time the
frontline was about 15km away. When
we heard the shelling, the teams would
prepare for mass casualties. Sometimes
military helicopters would fly over, and the
fear in our patients was palpable. In fact,
any time a plane or a helicopter flew over,
people would become nervous. When the
situation posed a more imminent threat,
we would gather our staff and patients into
a small, slightly more secure room.
The first patient I saw, and one that I won’t
forget, was a 12-year-old boy, wounded by
shrapnel. It’s always a shock to see civilian
casualties in war, but some stay with you.
The further away the frontline moved
from the hospital, the more internally
displaced people would come to the
hospital for assistance, and the more
burns patients we received, as a result of
living conditions in displacement camps.
Apart from that, Syria used to have a good
health system, so people used to receiving
healthcare suddenly didn’t know where
to turn. Earlier on in the conflict, we had
plans to open more paediatric facilities,
and centres for mothers and children. But
the opportunity for this diminished.

Question: How do the staff cope with the
constant threat of warfare, aren’t they
scared?
n Dounia Dekhili: Unfortunately, people
become used to it – it becomes normal for
them. But then you have events like the
recent chemical attacks (04.04.2017) and
understandably, staff become worried. We
put staff psychologists in place so that
our colleagues have someone to turn to,
but obviously working remotely means we
can only offer a phone line. It’s not ideal,
but people do use it. When more parties
became involved in the war, notably
when the Russian intervention began, the
bombing intensified. People were certainly
scared after that.
A lot has changed in this war, but the
one constant has been the total disregard
for civilian protection. Not just from the
warring countries, but those who refuse to
give refuge.
Question: What do you think hasn’t
been said, that is worth saying?
n Dounia Dekhili: We see a lot of
images and reports on military action,
a lot of discussions on the war itself,
but very few reports on the mass
displacement and human costs that go
beyond numbers. There isn’t a human
face to this war.

MSF regional branch office in UAE
MSF has been in the UAE since 1992, under the patronage of His Excellency Sheikh Nahyan Bin Mubarak Al Nahyan and is a member of International Humanitarian City (IHC). MSF’s work in the UAE includes support
for medical humanitarian assistance and operations in Iraq, Syria, Jordan,
Turkey, Yemen and Lebanon. In addition, MSF UAE is the primary logistical hub providing medical assistance to people based in Afghanistan, which
remains one of MSF’s largest operational programmes, with 2,303 full-time
staff and 366,000 outpatient consultations held in 2015.
l Visit: www.msf-me.org

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H E A L T H I 49

Conferences & Expos

KIMES 2017 – the largest
show in its 33-year history
The 33rd edition of South Korea’s largest
medical expo – Korea International Medical & Hospital Equipment Show (KIMES
2017) – took place at the COEX (Convention & Exhibition Center) in Seoul
from 16-19 March under theme “Smarter,
Easier, Healthier”.
The organizers – Korea E & Ex Inc., Korea Medical Devices Industrial Coop. Association and the Korea Medical Device
Industry Association – say the purpose of
the event is to provide assistance to the
further development of the medical equipment industries in Korea and neighbouring
countries, as well as the promotion of trade
in medical equipment, on both the domestic and international fronts.
This year was KIMES’s biggest show in
its 33-year history and comes on the back
of growth of more than 10% annually in
the medical device industry in the past decade in Korea.
KIMES 2017 attracted 226 companies
from 61 countries. Exhibitors came from
around the world including 579 Korea
manufacturers, USA 125, Japan 62, Germany 88, China 154 and many others.
The show highlighted the increasingly
important role played by domestic companies, Samsung, Listem, DK Medical, BIT
Computer and Alpinion, among others. In
addition, global brands such as Fuji, GE,
Philips, Shimadzu, Toshiba also had a big
showing at the event.

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The event was attended by more than
73,000 visitors and more than 3,500 overseas buyers from 92 countries.
At the event, the organisers set up a
Global Bio & Medical Plaza which served
as the principal platform for facilitating
cooperation and trading between Korean
and overseas companies in the bio and
medical industries.
Run concurrently with the expo were
180 sessions of seminars covering topics
such as government policies on the medical devices market and new medical device
technologies.

SMARTTECH
SMARTTECH and its Korean distributor,
the KAIS Company, presented for the first
time their 3D-scanning technologies dedicated to medicine, called scan3Dmed.
Due to growing interest from health and
security sectors, SMARTTECH designed a
new device for medicine. 3D scanning is
an innovative technology used on a daily
basis in industry, however it is still very
new in medicine. Non-industrial specialists require a user-friendly 3D scanner
that delivers reliable and accurate results.
There’s no time for long preparation of the
3D scanner before taking measurements
of the patient. SMARTTECH technology
allows both fast measurement and plug &
scan process, meaning that the scanner is
ready to work straight out of the box. This

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is possible due to the manufacturer’s permanent calibration that assures metrologically referential results.
Scan3Dmed is unique in that it can create
a comprehensive 3D digital representation of

Conferences & Expos

the patient. Accumulated records can be infinitely duplicated and shared with research
centres around the world, revolutionizing
the way of obtaining data in medicine.
Touchscreen technology allows comfortable work without any sophisticated
measurement knowledge from the operator. The intuitive software interface helps
provide data analysis with full understanding from the doctor’s side as well as the
patient’s side. Integrated CPU eliminates
the need of having a separated computer
to operate the device.
Using the panoramically merged results,
the doctor can create a virtual model of
the body and then do all types of measurements, that can become very helpful during treatment planning. The device’s new
multithreaded SMARTTECH software,
data calculation and precise analysis can
be done in a single visit of the patient.
● http://smarttech3dscanner.com/
Person Medical
Person Medical specialises in manufacturing autoclaves and EO gas sterilizers and
with their 20 years of experience they have
recently launched a series of low temperature plasma sterilizers, HPS35/50/80L.
The HPS Series of plasma sterilisers are
the most secure sterilizers, replacing current EO gas and formalin sterilizers which
use dangerous materials (sterilant) for
their sterilization. While harmful components that impact the human body and
the environment are discharged during
the emission process of EO gas and forma-

lin sterilization, the HPS Series are harmless and eco-friendly plasma sterilizers that
decompose hydrogen peroxide into water
and oxygen after completion of the sterilization process.
The HPS Series provides an optimized
sterilization environment to instruments
vulnerable to heat and moisture. Three
different sterilization cycles in the HPS series are programmed to fit the length and
characteristics of heat-sensitive medical
devices and surgical instruments.
The chamber is made of aluminium alloy that enables perfect sterilization by
maximizing the transfer of heat to sterilized instruments.
The HPS Series plasma sterilizers can
complete all process within a minimum
of 28 minutes while EO gas and formalin sterilizers require at least 12 hours of
sterilization and aeration for usage. The
HPS Series is economical as they facilitate rapid processing and reduce the cost
of operation.
HPS Series are installed using ordinary
power supply (AC220V) and can be installed anywhere in a hospital as an exhaust pipe or a drain line are not required
due to it having no toxic material.
● www.personmedi.co.kr
Samsung Medison – innovation in
ultrasound
Samsung Medison had a large booth to
showcase their many new medical devices
and equipment.
The company introduced a number of
advanced imaging software packages for
their ultrasound machines. ‘Crystal Clear
Cycle’ enables diagnoses of foetus health
and women’s diseases, which can happen
during six recurring circumstances of ‘family planning, measurement of foetal development, foetal abnormality test, diagnosis
of foetal image, delivery, and the diagnosis
of breast/female cancer.
With the detailed imaging software
technology of Samsung Medison, which
has provided ob-gyn ultrasound devices
for many years, ‘Crystal Clear Cycle’ is expected to be utilized in various ob-gyn diagnoses from pregnancy to women’s diseases.
Crystal Clear Cycle of Samsung Medison
helps diagnose ovarian cancer by applying
‘ADNEX,’ a risk model for the diagnoses

of adnexal tumors, which was presented by
the IOTA (International Ovarian Tumour
Analysis). ‘IOTA-ADNEX’ is equipped in
the ultrasound for the first time in the industry. Crystal Clear Cycle can predict the
risk of benign/malignant ovarian tumors
with nine variables. When it is malignant,
the risk will be divided into borderline,
stage I, end stage, or metastatic cancer.
‘Crystal Vue’ offers advanced technology
in the field of foetal imaging. Applying 3D
volume rendering technology, Crystal Vue
can show not only the surface area of the
uterus but also the internal tissues. It also
delivers analytical information to help distinguish the bone and the surrounding soft
tissues. Also included is ‘Crystal Vue Flow’,
a further advanced version of Crystal Vue.
Crystal Vue Flow provides information on
the foetus and placenta with additional information on blood flow on the surface and
internal tissues of uterus region.
Samsung Medison also developed ‘ECervix’, which will help diagnose the risk
of premature birth. By measuring the elasticity ratio of inside and outside entrance
of the cervix, which can be caused by the
internal vibration inside the tissues including surrounding blood vessel, by the trembling of tissues, or by the foetal movement,
it quantifies the risk of premature birth,
which will help ob-gyn doctors diagnose
the risk of premature birth.
● www.samsungmedison.com

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H E A L T H I 51

Timesco reusable laryngoscopes
and preloaded single use handles
Timesco Healthcare Ltd, England, has
been at the forefront of laryngoscopes design, manufacture and innovative developments in intubation for over five decades.
Complete ranges of reusable “Optima”,
“Sirius” laryngoscopes systems covering
from neonate to adult intubation, as well
as specialist, Robert Shaw, Seward, and difficult intubation “Eclipse” tilting tip blades
are available.
Timesco’s range of laryngoscopes has been
further upgraded by addition of LED light
for the reusable and single use handles.
Timesco manufactures the world’s number one single use disposable fibre optic la-

ryngoscopes system “Callisto”,
which is complemented with
Callisto single use and
Optima reusable LED
handles.
The single use Callisto range has been
expanded with the addition of Callisto Flare LED single use dry
cell and preloaded handles which are supplied complete with batteries. The Callisto
Flare LED handles are available individually and also paired with the Callisto blades
as handle and blade packs, ready to use.
We have regional distribution in the Mid-

Calculi Characterization, and gout.
In addition to these CT-optimizing features, the Symbia Intevo Bold SPECT/CT
system offers established cutting-edge capabilities in SPECT imaging. For example,
xSPECT Quant quantification technology
enables automated, accurate, and reproducible quantification of not only Technetium-99m – the most common isotope
in SPECT imaging – but also Iodine-123,
Lutetium-177, and Indium-111. This capability extends the use of advanced SPECT
quantification from general nuclear medicine and bone studies to indications including neurological disorders, neuroendocrine
tumors, and prostate cancer.
● For more information, visit:
www.siemens-healthineers.com

Siemens launches
new SPECT/CT
Siemens Healthineers has launched the
Symbia Intevo Bold SPECT/CT – a system that combines the company’s singlephoton emission computed tomography
(SPECT) technologies with new, highperformance CT capabilities to enable a
wide range of clinical applications. These
new CT options help make even challenging exams a matter of clinical routine.
Available on a Siemens Healthineers
SPECT/CT system for the first time, the
SAFIRE (Sinogram Affirmed Iterative Reconstruction) algorithm delivers excellent
CT image quality while reducing patient
radiation dose by as much as 60%. SAFIRE
enables fast image reconstruction for easy
implementation into a facility’s clinical routine. Additionally, SAFIRE reduces noise
while maintaining detail visualization.
Also available for the first time on any
of the company’s SPECT/CT systems, the
iMAR³ (Iterative Metal Artifact Reduction) algorithm reduces metal-related artifacts caused by metallic materials, such
orthopedic and dental implants. With this
capability, customers can not only curb
or eliminate artifact-induced distortion
in CT images but also apply the CT images for attenuation correction to provide

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H E A L T H

Dickies® LabCoat with CERTAINTY
Antimicrobial Technology™
Newly launched in the market,
Dickies Medical Lab coats are
made with our Certainty and Certainty PLUS antimicrobial fabric.
CERTAINTY PLUS ™ features antimicrobial and fluid
barrier fabric technologies.
The combined technologies are available in durable, breathable, soft, comfortable and in fashionable
range of lab coat for men,
women and unisex.
The advanced technologies in CERTAINTY
provide odour control and
feature fluid resistance that
causes many fluids to bead up
and roll off the apparel. Products
with CERTAINTY PLUS are enhanced with a revolutionary fabric
technology that uses nanotechnology to create fluid and stain resistance without clogging the fabric weave or compromising the look,
feel or comfort of the fabric.
Healthcare workers and other scrubs-wearing professionals often work long hours in conditions that can produce undesirable
fluids and odours. Now healthcare professionals can choose lab
coats that resist liquids, feature antimicrobial fabric technology,
remain naturally soft and breathe
● To order: Products available on www.souq.com
● For more info: www.dickiesmedical.com /
Williamson-Dickie Middle East FZE 04 887 8223

Abbott brings Sekisui CP3000
coagulation system to Middle East
Abbott announced that the Sekisui CP3000 coagulation system, a
fully automated analyzer that tests bleeding and clotting function in
blood, is now available in Europe, the Middle East, and Asia Pacific.
Abbott is the exclusive global distributor of the CP3000 coagulation
system in the US, Europe and other countries that recognize CE Mark.
The CP3000 coagulation system seamlessly integrates with Abbott’s suite of informatics solutions, which help accelerate efficiency in high test volume laboratories where resources may be limited
and space and time is at a premium. Capabilities like Abbotts AlinIQ informatics and service offerings streamline operations and
provide intelligent laboratory insights through common reporting and dashboard views, make it easy for healthcare providers
to read and interpret patient results. The system also connects to
the ACCELERATOR a3600 automation track, which provides
additional flexibility to meet the needs of the laboratory.
Delays in coagulation testing are often related to sample errors and
manual errors in the testing process. CP3000 coagulation system provides automated, standardized sample management, and can flag unsuitable samples at the start of testing. The system offers an expanded
menu of barcoded reagents to reduce data entry errors. With a unique
ability to visualize and automate Mixing Studies, the CP3000 coagulation system can help clinicians quickly interpret results.
● For more information, visit: www.corelaboratory.abbott/int/en/
offerings/segments/coagulation-seg

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H E A L T H I 53

Image captured from video
- Ajiboye et al, Restoration
of reaching and grasping
movements through
brain-controlled muscle
stimulation in a person with
tetraplegia: a proof-of-concept
demonstration. Copyright
(2017), with permission from
Elsevier.

Reprinted from The Lancet

The Back Page

Neuro-prosthesis reconnects brain
to muscles to restore functional arm
movements to man with complete paralysis
A system that decodes brain signals and
transmits them to sensors in the arm has
allowed a man paralysed from the shoulders
down to regain movement in his hand and
arm, according to the first study to report
results for this new technology, published in
The Lancet.
Although only tested with one
participant, the study is a major advance
and the first to restore brain-controlled
reaching and grasping in a person with
complete paralysis. The technology, which
is only for experimental use in the USA,
circumvents rather than repairs spinal
injuries, meaning the participant relies on
the device being implanted and switched
on to move.
“Our research is at an early stage, but
we believe that this neuro-prosthesis
could offer individuals with paralysis the
possibility of regaining arm and hand
functions to perform day-to-day activities,
offering them greater independence,” said
lead author Dr Bolu Ajiboye, Case Western
Reserve University, USA. “So far it has
helped a man with tetraplegia to reach
and grasp, meaning he could feed himself
and drink. With further development, we
believe the technology could give more
accurate control, allowing a wider range of
actions, which could begin to transform the
lives of people living with paralysis.”
Injuries to the spinal cord often cause
loss of muscle function and paralysis, with
injuries affecting the vertebrae in the neck
region usually causing full paralysis of all
four limbs.
Previous research has used similar

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elements of the neuro-prosthesis. For
example, a brain-computer interface linked
to electrodes on the skin has helped a
person with less severe paralysis open and
close his hand, while other studies have
allowed participants to control a robotic
arm using their brain signals. However, this
is the first to restore reaching and grasping
via the system in a person with a chronic
spinal cord injury.
In this study, a 53-year-old man who had
been paralysed below the shoulders for eight
years underwent surgery to have the neuroprosthesis fitted.
This involved brain surgery to place
sensors in the motor cortex area of his
brain responsible for hand movement –
creating a brain-computer interface that
learnt which movements his brain signals
were instructing for. This initial stage took
four months and included training using a
virtual reality arm.
He then underwent another procedure
placing 36 muscle stimulating electrodes
into his upper and lower arm, including
four that helped restore finger and thumb,
wrist, elbow and shoulder movements.
These were switched on 17 days after the
procedure, and began stimulating the
muscles for eight hours a week over 18
weeks to improve strength, movement and
reduce muscle fatigue.
The researchers then wired the braincomputer interface to the electrical
stimulators in his arm, using a decoder
(mathematical algorithm) to translate
his brain signals into commands for the
electrodes in his arm. The electrodes

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stimulated the muscles to produce
contractions, helping the participant
intuitively complete the movements he was
thinking of. The system also involved an
arm support to stop gravity simply pulling
his arm down.
During his training, the participant
described how he controlled the neuroprosthesis: “It’s probably a good thing that
I’m making it move without having to
really concentrate hard at it. I just think
‘out’ and it just goes.”
After 12 months of having the neuroprosthesis fitted, the participant was asked
to complete day-to-day tasks, including
drinking a cup of coffee and feeding
himself. First of all, he observed while his
arm completed the action under computer
control. During this, he thought about
making the same movement so that the
system could recognise the corresponding
brain signals. The two systems were then
linked and he was able to use it to drink a
coffee and feed himself.
“Although similar systems have been
used before, none of them have been as
easy to adopt for day-to-day use and they
have not been able to restore both reaching
and grasping actions,” said Dr Ajiboye.
“Our system builds on muscle stimulating
electrode technology that is already
available and will continue to improve with
the development of new fully implanted and
wireless brain-computer interface systems.
This could lead to enhanced performance
of the neuro-prosthesis with better speed,
precision and control.”
l doi: 10.1016/S0140-6736(17)30601-3

Middle East Health is the region’s only
independent English-language medical
trade magazine. It is the oldest and most
well-established medical trade magazine
in the region having served the healthcare
industry for more than 40 years.
* Features may be subject to change.

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